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IN PREPARATION. 



A PRACTICAL TREATISE 

ON THE 

DISEASES OF WOMEN. 



One Volume. Octavo. Fully Illustrated. 



Practical Treatise 



ON 



HERNIA. 



BY 



JOSEPH H. WARREN, M.D., 

MEMBER AMERICAN MEDICAL ASSOCIATION; BRITISH MEDICAL ASSOCIATION 

MASSACHUSETTS MEDICAL SOCIETY ; FORMERLY SURGEON AND 

MEDICAL DIRECTOR U.S.A.; ETC., ETC. 



— h 2- 



&econti anO &eirisc& lEDttton. 



FULLY ILLUSTRATED. 



W OF Ct 



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BOSTON: 
JAMES R. OSGOOD AND COMPANY. 

LONDON: 
SAMPSON LOW, MARSTON, SEARLE, AND RIVINGTON. 

1882. 

All rights of translation reserved by the author. 









Copyright, 1880, 1881, 
By Joseph H. Warren. 



University Press: 
John Wilson and Son, Cambridok. 



fe 



TO THE 

HONORABLE STUDENT AND REGULAR PRACTITIONER 

OF MEDICAL ART 

IN AMERICA AND IN EUROPE 

This Work is Respectfully Dedicated 
$2 % &«%*. 



PREFACE TO THE SECOND EDITION. 



The manner in which the First Edition of this work has 
been received by the profession is very pleasing to the author. 
The danger is that he who writes concerning a single operation 
will be considered an enthusiast. I trust, however, that the 
intrinsic value of this volume will be evidence that I have 
approached my subject in the spirit, not of an enthusiast, but 
of a searcher after truth. I have at all times endeavored to 
be liberal and impartial in my views and presentations of the 
various methods that have been employed for the relief and 
cure of hernia. 

The Introduction to the former edition has been entirely 
omitted, as has also the Appendix, giving urinary instruments 
of the author. To the original manuscript, a new Introduction 
and six wholly new and carefully written chapters have been 
added : Chapter L, Causation of Hernia ; Chapter X., Recent 
Operations for Hernia ; Chapter XL, Artificial Anus and 
Wounds of the Intestines ; Chapter XIIL, Hydrocele and 
Varicocele ; Chapter XIV., Observations on Hernia ; and Chap- 
ter XV, Resume and Clinical Reports. 

For the benefit of critics, the author would say that if stereo- 
type plates of the book had not been already cast, many of the 
additions, which must now be massed together into one chapter, 
could more appropriately have been introduced in the body of 
the text. For the benefit of readers, it may, however, be said 



vi PREFACE TO THE SECOND EDITION. 

that full and convenient references have been made throughout 
the book to these additions, so that no confusion of thought 
will result. 

Many new illustrations have been added by the heliotype 
process, besides three beautiful anatomical plates, two of them 
reproduced from Bourgery, and the third from Blandin. The 
Index has been revised and enlarged, while the Bibliography 
has been more than doubled, — the author having given much 
care in London to the collection of the literature upon the 
subject. 

In addition to all this, what was previously published has 
been carefully revised, much of it rewritten, and many typo- 
graphical errors corrected which were previously unavoidable. 
The microscope has revealed to me nothing that is new in the 
pathology of plastic lymph in the hernial rings. 

While the mere specialist may possibly think the Treatise 
too condensed in places, and the more general reader too minute 
in its details, the author has endeavored to take a happy 
medium, striving, however, to be practical rather than merely 
theoretical. Thanking the regular profession once more for 
their kind words of cheer and encouragement, he presents and 
dedicates to them this volume, which he trusts will be found a 
thoroughly comprehensive and practical Text-book on Hernia. 



51 Union Park, Boston, Mass., U. S. A., 
July, 1881. 



PREFACE. 

It lias been the author's desire in placing the present work 
"before the medical profession to do so in as concise a form 
as possible. There seemed to me great need for a work like 
the one now issued, giving a short sketch of the various opera- 
tions for the cure of Hernia that are most worthy of mention, 
in order that the busy practitioner could refer to them without 
wading through whole volumes. 

Much labour has been bestowed upon the little monograph, 
and very many authors consulted. I have striven, with the 
time at my command, to make a trustworthy work of reference 
on Hernia, although it is far from being as perfect or as 
extended as I should like. It will be found to contain much 
that is original with the author (the result of the study of 
Hernia for many years), and never before given to the pro- 
fession in a printed form. Besides this will be found a 
condensation of many operations from the French, German, and 
English. A short Bibliography is given to indicate some of the 
work that has been devoted in previous years to the subject 
under consideration. 

I am under many obligations to my very kind and generous 
friends in the profession, both in my own country and in others, 



viii PREFACE. 

who by encouraging and cheering words have done much to 
aid me in accomplishing my task. I am under the most par- 
ticular obligations to my son, Charles Everett Warren, A.B., 
Student in Medicine, and to my nephew, Willard Everett Smith, 
A.B., Student in Medicine, for the very great amount of labour 
and assistance they have rendered me in translating from the 
French and German, and in compiling these pages. Had it not 
been for their great interest and assistance I could not at such 
short notice have prepared the work. 

To Messrs. Geo. Tiemann and Co., of New York, I am 
indebted for great assistance in the perfection of my various 
instruments, as well as for the loan of several electrotypes. 
Messrs. Codman, Shurtleff, and Co., of Boston, also supplied 
several electrotypes, and Dr. Codman has furnished me with 
an article on trusses. 

I am also under obligations to Messrs. Weiss and Son, 
London, who so readily conceived my ideas in regard to a 
lithopaxy tube, and other instruments of great beaut}'- and 
finish. 

In conclusion, I would gratefully acknowledge the favour 
received from Prof. G. Dowell of Texas, and Dr. H. 0. Marcy 
of Cambridge, Mass., whose operations are inserted in the 
body of the work. 

I would express great obligation to Sir Henry Thompson 
for the favour which he showed me in allowing me to witness 
his operation for lithopaxy a number of times, and in explain- 
ing his operation and instruments to me ; also I am grateful 
to Thomas Bryant for his great kindness to me in allowing 
me to use illustrations from his work, and for affording me 



PREFACE. ix 

an opportunity to operate on Hernias before a number of 
surgeons at Guy's Hospital. 

And also to my very kind friends Dr. Brown Sdquard of 
the College of France, who recommended me to the Academy 
of Medicine ; to Dr. AlphoDse Guery, Surgeon to Hotel Dieu, 
who very kindly presented me, and explained my instruments 
more fully at the Academy ; and to Dr. Blum, Surgeon to 
the Hospital Beaujon, who kindly assisted me in my demon- 
stration of the operation for Hernia and other operations 
with the new instruments of my devising. 



CONTENTS. 



-♦- 



PAGE 

Introduction , xiii 

CHAPTER I. 
Hernia: Causation . . , ; . . . 4 

CHAPTER II. 
Hernia : Kinds and Frequency .,..,.... 37 

CHAPTER III. 
Anatomy: Descriptive and Surgical 48 

CHAPTER IV. 
Strangulated Hernia . »-.■»-, 85 

CHAPTER V. 
Operations for Hernia 93 

CHAPTER VI. 
Author's Operation by Injection 134 

CHAPTER VII. 
General Remarks .,....., 175 

CHAPTER VIII. 
Treatment op Strangulated Hernia : Taxis .... 208 



xii CONTENTS. 

CHAPTER IX. 

PAGE 

Kelotomy ok Herniotomy 217 

CHAPTER X. 
Recent Operations for Hernia 243 

CHAPTER XI. 
Artificial Anus, and Wounds of the Intestines . . 303 

CHAPTER XII. 
Trusses 312 

CHAPTER XIII. 
Hydrocele and Varicocele . 324 

CHAPTER XIV. 
Observations on Hernia . 341 

CHAPTER XV. 
Resume and Clinical Reports 379 



Bibliography 405 

Index 421 



HERNIA. 



INTRODUCTION. 

" I believe the time is coming when most cases of reducible hernia will 
be radically cured by the surgeons, if not of this generation certainly of 
the next." — Sir T. Spencer Wells. 

While it is right and fitting that in a Practical Treatise on 
Hernia we should consider all the various methods and devices 
that have been suggested for its relief and cure, sufficiently at 
least to give the student and general practitioner an idea of the 
field open for more minute study, if any are interested in looking 
at the subject in its historical aspect, I do not consider it neces- 
sary for me at this period of general information and intelli- 
gence to develop to their full extent all the operations that have 
been performed, but will give more special attention to those 
that seem more worthy of commendation. 

" Look not mournfully into the past. It comes not back again. Wisely 
improve the present. It is thine. Go forth to meet the shadowy future 
without fear and with a manly heart." 

It is altogether probable that from the very earliest times 
mankind has been afflicted with hernia, even before the dawn 
of history had given us any records. Many of the ancient 
operations for the cure of this affection have come down to us 
from the early surgeons ; but it does not tax the ingenuity to 
any great extent to suppose that the wandering nomadic tribes 



xiv INTRODUCTION. 

of the East, as well as the more uoble and civilized builders of 
the Egyptian pyramids, were conversant both with the disease 
and methods of its cure. Since every day brings to light new 
evidences of the culture and civilization of Egypt, it is no great 
stretch of the imagination to suppose that the Oriental surgeons 
knew of a subcutaneous injection of some stimulating and astrin- 
gent fluid into the hernial rings. We know beyond a doubt that 
from the most remote ends of the inhabited earth patients 
flocked to the Egyptian surgeons to be healed ; and we know 
that in their process of embalming they showed no want of 
proper anatomical knowledge, and that they made no little use 
of the astringent properties of tannin in the abdomen in the 
preservation of their dead. 

Whether our suppositions in regard to their knowledge of in- 
jection be true or not, we do not know. We do know that, 
during the ages of darkness in Europe, surgical knowledge and 
the treatment of hernia were kept alive by the ancient Arabs 
who in olden times were remarkable for their scientific attain- 
ments. It is altogether probable also that the ancient Israelites, 
the chosen people of God, were acquainted with hernia and its 
cause, prevention, and treatment ; and if, as we shall see further 
on, phimosis be a great cause of hernia in children, may it not 
be that the law of circumcision was divinely given, as well for 
the prevention of hernia, as for the preservation of cleanliness 
and the prevention of syphilis and urinary diseases, which, by 
causing stricture and obstruction, produce straining and con- 
sequently hernias. 

That syphilis and gonorrhoea, as well as phimosis, do have 
a marked influence upon hernia and its treatment, we all know 
from our professional experience. I have frequently observed 
that persons who have had extensive suppurations from lues 
veneria are more liable to have bad and complicated forms 
of hernia than more healthy persons, because the abundant for- 



INTRODUCTION. xv 

mation of pus had caused a loosening and weakening of the 
tissues of the groin. Since the Orientals hated the spilling of 
blood in their surgical treatments, they made use of poultices 
and plasters of astringent substances, whether tannin or pome- 
granate ; and it may be that the records will sometime show 
that they also employed astringents internally for the relief of 
an affection that must have afflicted them. 

The nineteenth century has witnessed a revolution in medical 
and surgical science. It has seen ether and chloroform giving 
comfort to both patient and operator, so that operations can now 
be performed which before our time would never have been 
dreamed of. It has seen wonderful advances made in the treat- 
ment of diseases of the eye, ear, and throat, in the diagnosis of 
affections of the chest, and in the removal of fluids from the 
body. Why, it was only in 1856 that I performed the opera- 
tion of paracentesis thoracis with a thumb lancet and a female 
catheter. This, I think, was one of the very earliest operations 
of this kind in this country ; yet to-day it is of every-day 
occurrence in our practice. It has seen surgery made safe by 
the use of antiseptic precautions ; and I thought, while recently 
assisting a brother physician to remove the entire uterus and 
ovaries from a suffering woman, that the conservative surgery 
of the future will save many precious lives for usefulness that 
our fathers would have given up for lost. We may, therefore, 
with perfect truth and confidence say that our profession has 
ever been, and is to-day, fully as progressive in its advance 
toward scientific perfection as any other branch of art and 
science. 

Let us hail, then, with joyful gladness, all scientific measures 
that offer to relieve suffering or to save life ; and what grander 
field than hernia is offered for this work ! By endeavoring to 
relieve the sufferings that this scourge entails upon mankind, we 
shall take no undue praise to ourselves, but we may safely 



xvi INTRODUCTION. 

claim the satisfaction of performing well our duty "both to our 
patients and our profession, and shall preserve in all its sanctity 
the ever-binding oath of Hippocrates to preserve life and never 
to destroy it. Let " Droit et Eoyal " be our motto, and " Verite 
clans la Science " our greatest desire in the practice of our art. 

Like many other diseases which the profession has pronounced 
incurable, it has been the fate of hernia to fall into the hands of 
unscrupulous men, who in every age have obtained a spurious 
reputation for curing a disease concerning which it is not in 
some cases easy to decide whether it can be cured or not ; — 
a disease which is not to be distinguished, except by experienced 
surgeons, from many others which are easily curable. In both 
ways the public have been deceived repeatedly, and professional 
men are naturally placed in an attitude of suspicion toward all 
such attempts to remove the stigma of impotence which in too 
many instances is fixed upon their art. 

In these latter days of attention to the social sciences, we 
justly consider the physical qualities of races and their deteriora- 
tion to be of paramount importance. Habits of active exertion 
and muscular training are encouraged with a view to military, 
scientific, mercantile, and colonizing pursuits. Doubtless the 
frequency of hernia, great as it already is, will be thereby in- 
creased until these habits have invigorated more than one 
generation and impressed its influence upon their descendants. 
Thus has arisen an increasing demand for something to be done 
for herniae, leading to the revival of attempts to cure this pre- 
vailing deformity, although most of them in the past have 
proved futile. 

Hernia, especially inguinal, is a very common disease, more 
particularly in those classes of men who are the backbone and 
support of nations ; namely, the laboring, military, and naval 
classes. The disease renders them incapable, for the most part 
totally, of the effective performance of their duties, and may 



INTRODUCTION. xvii 

place their lives in jeopardy under circumstances in which their 
greatest efforts are required and surgical help not available. 
This result has been found by experience not to be effectually 
guarded against by the use of trusses, which often fail just when 
most needed or cause so much trouble and expense that they are 
discontinued as unprofitable. Before we can obtain a proper 
light from statistics on this subject, we must compare the total 
number of deaths from attempted radical cure with those from 
strangulation and other fatal consequences of hernia, and the 
proportions of each to the total number of hernias This alone 
will show whether society at large is a gainer by the many 
radical cures that have been proposed. 

It is a question generally asked of the surgeon by the patient, 
" Is the operation a safe and certain one " ? The answer will 
vary somewhat with the experience and more probably w T ith the 
individual character of the surgeon. The most reasonable defini- 
tion of a safe operation seems to be, " an operation which has no 
peculiar dangers arising from the situation of the parts or the 
method of procedure, and which is not subject more than others 
to those accidental diseases which may occasionally follow any 
interference whatever with the surface of the body, such as 
erysipelas, tetanus, and pysemia. 

" Next, — is the proportion of success to failure such as to 
offer to the patient chances of cure which will overbalance the 
dangers and inconveniences of a hernia treated by a truss more 
or less efficient ? In estimating this, it must be borne in mind 
that in almost all of the cases called unsuccessful the patient is 
in a better condition than before the operation, inasmuch as a 
truss is rendered effective which had previously failed in keeping 
up the hernia. In none of the cases has the condition of the 
patient been rendered worse." * 

* Wood, on Rupture. 



CHAPTEE I 

Causation of Hernia. 

In the following consideration of hernia, we shall discuss 
minutely the Causation of Hernia in foetal and infantile life, and 
devote a few more general remarks to its causation in adults. I 
have deemed this the better arrangement, since the consideration 
of the former variety of hernia rests upon an exact anatomical 
and physiological knowledge, and upon conditions which affect 
both infants and adults, while the causation of the latter variety 
is more problematical and rests upon many and varied inherited 
predispositions, as well as upon conditions and habits of life 
which differ with the individual. 

I shall, for these purposes, beg leave to extract freely from 
many different authors, selecting from each such portions as I 
shall judge will present to the reader and student the very best 
and most recent views upon the subjects in question. I wish 
in this place to acknowledge my very great indebtedness to the 
writings of Scarpa, Birkett, and John Wood, both for many 
suggestions and quotations. 

Congenital Inguinal Hernia. — As an introduction to the 
proper understanding of this subject, the following extracts from 
a paper by Allan Burns, of Glasgow, published in " Munroe's 
Outlines of Anatomy," are very valuable : In the foetus or 
new-born male, we find that the tendon of the external oblique 
muscle at its anterior and inferior part separates into two pillars, 
which leave between them an irregular opening through which 



CAUSATION OF HERNIA. 5 

the cord passes. Both pillars inclining toward the crest of the 
pubes, one is completely lost, the other in part implanted. That 
fold which passes below the cord is completely implanted into 
the tough ligament which covers the tubercle of the pubes. The 
other pillar, when it reaches the pubes, separates into two bands ; 
the posterior or deeper is inserted along the lower pillar into 
the tubercle of the pubes, and extends even to the opposite side. 

The other, and by far the most important band, winds obliquely 
inward, then bending backward between the penis and the cord, 
is at last incorporated with the fascia of the triceps, covering 
the heads of the triceps, the gracilis, and flexor muscles of the 
le<*. In some cases it can be traced much further and reaches 
even to the tendon of the gluteus maximus, to which it is 
attached. The slip from the upper pillar of the canal is always 
inseparably joined to the fascia covering the cremaster ; indeed 
it may perhaps most properly be described as a part of Camper's 
fascia, i.e., the cremasteric sheath attached to the ring. " I 
thought," says Burns, " that this structure had not been noticed 
by any author, but I find that it has not escaped that indefati- 
gable anatomist, Camper." This part of the canal merits peculiar 
attention, for whoever is ignorant of the position and connection 
of the production of the upper pillar of the ring can possess only 
a very confused notion of its action in disease. 

When we have examined in the very young subject the struc- 
ture of the external orifice through which the cord passes, we 
have seen all that is most worthy of notice ; for in the very 
early part of life, the inguinal canal is not formed. I have never 
observed the cord in any obvious degree oblique in its course. 
In an infant at birth, it runs in a straight line from the psoas 
muscle to the bottom of the scrotum, and passes through a mere 
aperture. When, however, w T e take a subject even a month old, 
we find there is a very apparent obliquity in the course of the 
cord. If we examine subjects of different ages, we find that 



6 HERNIA. 

the older they become until they arrive near the age of puberty, 
so much the longer does the inguinal canal become. 

It may be worth while to inquire how the canal comes to be 
formed, and what changes take place in the neighboring parts. 
I have already said that the upper and lower openings of the 
foetal ring are opposite to each other, and so very little distinct 
the one from the other that there is hardly a calculable space 
between them. The ring is placed just in contact with the 
tubercle of the pubes. The lower outlet in the foetus is there- 
fore in the same spot which it is afterwards to occupy in the 
adult. In proportion therefore as the foetal ring is changed into 
the adult canal, it is the internal orifice which changes its posi- 
tion. It is the upper opening which ascends toward the spine 
of the ilium. From this we may very readily understand that 
it is the gradual extension of the transversalis fascia in this 
direction which encloses the cord in the canal. 

A very simple contrivance gives a very clear idea of the man- 
ner in which the inguinal canal is formed. Let any one take 
two slips of paper of the same length, and cut two small holes 
in the centre of each. Let him then lay these holes opposite 
each other, and pass through them a quill or pencil case. 
When he has done this, he has a very good plan of the state of 
the parts about the groin in the foetus. If he now holds the 
papers opposite him, and then pulls to one side the one nearest 
to him, he will find that by so doing he comes to lay the quill 
between the pieces of paper in the same way that the spermatic 
cord, by the extension upward and outward of the internal orifice 
of the ring, comes to be lodged in the long canal. He will also 
see that the length of the canal must vary according to the 
greater or less extension of its posterior side. On pages 56 and 
69 of this present work it will be seen that the author has 
expressly stated that the inguinal and femoral canals are not 
properly canals unless distended by a hernia. In a normal state 
they are simply flattened passages. 



CAUSATION OF HERNIA. 7 

It is this close apposition of the tissues that first led the 
author to consider the feasibility of producing union of all these 
parts by exciting a certain amount of inflammation and the 
exudation of plastic lymph. If we bear in mind this anatomical 
relation, we can readily see the practicability and propriety of the 
operation of injecting into these parts some stimulating fluid 
which may excite and bring about this desired object. The 
careful anatomist sees that in proportion to the degree in which 
the posterior side of the canal overlaps the anterior, so must the 
length of the canal vary. He will thus understand why in- 
guinal hernia is much more frequent in young than in old sub- 
jects, why it is often cured spontaneously in the former and 
seldom in the latter, and why in the one it is a more dangerous 
affliction than in the other. 

In the advanced stage of hernia, the parts are brought into 
precisely the same state they were in when the disease began. 
In a congenital hernia, or in the common inguinal hernia taking 
place in a very young child, the sac passes through a mere aper- 
ture ; then we see that in time, owing to changes which this 
opening undergoes, the gut is lodged in a canal, so-called. This 
continues until the tumor becomes large, when the posterior side 
of the canal, owing to the pressure, is slowly absorbed, and 
again the upper and lower orifices are brought opposite to eacli 
other, so that the hernia resembles, in its appearance and course, 
the incipient tumor. If this view of the anatomy be a correct 
one, we see that by preventing the descent of the intestines, and 
by returning the sac, we bid fair to cure the disease by allowing 
the extension of the posterior side of the canal along the cord 
to take place. 

In the very young child, there is no security against hernia, 
except what arises from the cord filling the aperture through 
which it passes. This is generally sufficient, for the infant is 
exposed to few of the exciting causes of the disease. In later 



8 HERNIA. 

life, nature has wisely provided that, in proportion to the danger, 
the security should be increased. The posterior side of the 
canal overlaps, every day more and more, the anterior side ; con- 
sequently, when the canal is completed, any pressure against the 
posterior side, tending to produce hernia, has the effect of laying 
that side more firmly in contact with the cord, and of forcing the 
latter steadily against the anterior side, where the fibres of the 
transversalis and internal oblique muscles react upon it. Thus 
a most perfect valve is formed, and, when the posterior side of 
the canal is fully extended, it is impossible that inguinal hernia 
can take place except by violence. When hernia has once taken 
place, the very objects which formerly had a tendency to prevent 
the descent of the intestines are now so far changed in their 
action that they present obstacles to their replacement. 

In the congenital form of hernia, the sac is formed of that 
portion of the peritoneum formed by the descent of the testicle. 
The passage of the testis through the inguinal canal usually 
takes place about the eighth month of infra-uterine life. Under 
conditions retarding the rate of development, this transit may 
be delayed until after birth, and may be observed to occur at 
any period during the first few years. 

Cases are not uncommon in which this descent is retarded 
until the period of puberty has passed. In such instances, the 
gland is almost always retained permanently within the abdo- 
men by adhesions to the colon or parietes, and is usually more 
or less atrophied. (See page 15.) Sometimes it is arrested in 
the inguinal canal itself, and is not infrequently mistaken for a 
hernia. The differential diagnosis may be found in the table on 
page 81. The impulse given to the gland, upon coughing under 
these circumstances, results from the presence of a portion of 
intestinal omentum in a cul-de-sac of the peritoneum, arrested in 
its developments into the tunica vaginalis in the male, and 
into the canal' of ISTuck in the female. 



CAUSATION OF HERNIA. 9 

Certain writers have supposed that the gubernaculum testis 
possesses the power and has the function of drawing down the 
testis through the inguinal canal. This gubernaculum attains 
its full development between the fifth and sixth months ; it is a 
conical-shaped cord attached, above to the lower end of the 
epididymis, and below to the lower portion of the scrotum. It 
is placed behind the peritoneum, lying upon the front of the 
psoas muscle, and completely fills the inguinal canal. 

According to Mr. Curling, in his " Practical Treatise on the 
Diseases of the Testis," the gubernaculum, as well as the muscular 
fibres of the cremaster which surround it, divides below into three 
processes. The external and broadest process is connected with 
Poupart's ligament in the inguinal canal, the middle process 
descends alom>" the inguinal canal to the bottom of the scrotum, 
where it joins the clartos, the internal one is firmly attached to the 
os pubis and sheath of the rectus muscle. Up to the fifth month 
the testis is situated in the lumbar region, covered in front and 
at the sides by peritoneum, and supported by a fold of that 
membrane called the mcsofchium. Between the fifth and sixth 
months, the testis descends into the iliac fossa, the gubernaculum 
at the same time becoming shortened. During the seventh 
month, it enters the internal abdominal ring, a small pouch of 
peritoneum (processus vaginalis) preceding the testis in its 
course through the canal. By the end of the eighth month, the 
testis has descended into the scrotum, carrying down with it a 
lengthened pouch of peritoneum. Just before birth, the upper 
part of the pouch usually becomes closed, shutting it off from 
the peritoneal cavity. 

Mr. Curling believes that the descent of the testis is effected 
by means of the muscular fibres of the gubernaculum ; those 
fibres which proceed from Poupart's ligament and from the ob- 
liquus internus are said to guide the organ into the inguinal 
canal, those attached to the pubis draw it below the external 



10 HERNIA. 

abdominal ring, and those attached to the bottom of the scrotum 
complete its descent. 

Although there can be but little doubt that the main cause of 
the formation of congenital hernia consists in the retardation 
and want of vigor of developmental changes, which seal up the 
inguinal rings and the canal after the testis has accomplished 
its transit, still there is great doubt that the descent of the 
testis above described is accomplished by the forcible retraction 
of the muscular fibres of the gubernaculum. More probably, 
the descent is by a simple growth taking place in different parts 
and in different directions at successive periods of foetal life. 

The gubernaculum in the human subject, therefore, has no 
proper function as an organ, but is merely the anatomical vestige 
or analogue of a corresponding muscle in certain of the lower 
animals, where it has really an important function to perform. 
In the rabbit, for instance, the serous pouch of peritoneum, 
which preceded the descent of the testis, remains in communica- 
tion with the peritoneal cavity even into adult life, so that the 
testis may be alternately drawn downward into the scrotum or 
retracted into the abdomen by the action of the gubernaculum 
and the cremaster muscle. 

Guthrie believes that the testis ascends or descends, as the 
case may be, at the proper period, for the same reason that a 
child is usually born at nine months in preference to any other 
period of uterine gestation, which is, as Avicenna says, by the 
will of God. The office of the gubernaculum appears to be 
therefore rather to keep a passage open, which might, if it were 
not occupied in this manner, be closed, than to operate upon the 
testis by any contraction of its substance. This view is still 
further strengthened by the anatomical fact, mentioned even by 
Curling, that the gubernaculum diminishes in size as the testis 
approaches the bottom of the scrotum. This diminution is not, 
however, in the muscular fibres, as we might suppose it would 



CAUSATION OF HERNIA. 11 

be if their function had ceased, but is owing to a change in the 
disposition of the cellular elements of the structure. 

As the testis passes through the transversalis muscle, it may 
carry down with it any fibres which lie in its way ; when this 
occurs, the transversalis is found to be united at this part to the 
internal oblique. The fibres thus brought down assist in the 
formation of the cremaster muscle, which is nothing more than a 
certain portion of the lower edge of the internal oblique, caught by 
the testis and carried before it, Curling to the contrary notwith- 
standing. See page Gl. When the testis is retained in the 
abdomen, it is not because of a lack of an opening in the trans- 
versalis or internal oblique muscles, but for some reason which 
has not yet been sufficiently explained, as the person usually 
suffers from a hernial protrusion because the parts are less de- 
fended than usual by the natural structures. 

If at the period of birth the testis has but just escaped from 
the canal, or still lies lodged above the external ring, the cries 
and struggles of the infant, during its first inspiratory movements, 
will force down a portion of the intestines into the canal. The 
continual recurrence of this protrusion will prevent the proper 
closure of the openings. As a rule, the later the descent of the 
testis through the rings, the larger and the less disposed to close 
is the hernial opening which results. In many individuals not 
ruptured in childhood, a late descent of the gland leaves a patu- 
lous condition of the external ring which greatly predisposes to 
the subsequent formation of a hernia ; since the only resistance 
in such cases is a limited extent of adhesion at the upper part 
of the canal and internal ring. It is generally associated also 
with a feebleness and deficiency of the lower fibres of the in- 
ternal oblique. 

I have at present, under my professional care, a patient 
neither of whose testes has ever descended. He is a physician 
fifty years of age, and the father of four children. He has 



12 HERNIA. 

double inguinal congenital hernia, oblique on. the right side, 
and direct on the left. The former descends into the scrotum, 
lying beneath and back of the testis, which can be felt in the 
external ring. The condition is the same on the left side, except 
that the hernia does not descend into the scrotum. The rings 
upon both sides are enormously enlarged. It is remarkable in 
this case that the testes will endure without pain pressure suffi- 
cient to allow a double truss to sustain the hernia?, and that 
they can also be freely handled. When, however, the patient is 
amorous and excited, the truss causes such extreme pain and 
almost faintness that, on account of the exhaustion, he has to 
abstain from such exciting influences. 

A similar formative deficiency in some of these cases may 
possibly account also 'for the non-descent of the testis. The 
peritoneum is usually lax and loose, and plentifully bestowed 
npon the superior false ligament of the bladder, which rises 
more than usual out of the pelvis when distended, and is broader 
in proportion to its depth. Upon dissection it is usually found 
that the peritoneum is thinned to its utmost extent by the 
gradual filling up and dilatation of its areolar meshes by a de- 
posit of fat. In the omentum particularly, it may be entirely 
perforated in many places so as to assume a cribriform appear- 
ance. In these cases the fat, which is the more temporary 
tissue, may have been more quickly absorbed by illness or star- 
vation than the containing tissues are able to contract and follow 
it. The inguinal and other hernial openings are left patulous, 
and the weakened and yielding peritoneum quickly contributes 
a thin sac to the rapidly forming hernia which results. 

It follows from this description that congenital hernia must 
necessarily be of the oblique variety, in its relation to the in- 
ternal ring and epigastric artery, and that a true direct hernia is 
rarely seen in the child. 

The student who bears in mind what has been previously said 



CAUSATION OF HERNIA. 13 

in regard to the inguinal canal, and the relative position of the 
rings to each other in the foetus and young child, will not 
by this statement be misled into the idea that congenital hernia 
in the child takes such an oblique course as external or oblique 
hernia in the adult. He will, however, readily see the vicious- 
ness of the term "oblique inguinal" hernia, the confusion and 
misunderstanding caused by it, and the worse than confusion 
caused by the misnomer " indirect," as sometimes applied to the 
same variety. In long-continued and neglected cases, as I have 
further emphasized on pages 7, 73, and 180, the internal and 
external openings are often closely applied to each other and 
the oblique hernia becomes in its treatment and the difficulty of 
its management like a direct hernia. 

In early foetal life, and in many cases for a month or so after 
birth, the tubular process of the peritoneum, which I have 
spoken of, extends into the scrotum, lying in front of the sper- 
matic cord and testis and extending from the internal inguinal 
ring to the lowest end of that gland. Before birth or soon after, 
this vaginal process of the peritoneum becomes divided into two 
portions, — the superior or funicular process, and the inferior or 
vaginal process. Under normal conditions the inferior, or vagi- 
nal process peculiar to the testis, remains throughout life as a 
closed serous sac, and the superior canal or vaginal covering 
peculiar to the spermatic cord, the funicular process, is entirely 
obliterated, and its superior abdominal orifice permanently closed. 

The time at which the closure of this ventral orifice takes place 
and the obliteration of the canal is completed is not fully deter- 
mined. The ^s^ stage in the obliteration begins at the upper 
part from the internal inguinal ring, at least on one side. The 
second stage is marked by a union of the Avails of the vaginal 
sheath as far as the superior end of the testis. The third stage 
is accomplished when the canal is entirely or partially closed, 
and when the serous membrane is converted into connective 



14 HERNIA. 

tissue. In the fourth stage, this strip of connective tissue be- 
comes thinner and at last disappears. 

In the majority of new-born infants, some portion of this vagi- 
nal canal still remains. In twenty-one cases, Seiler found four 
in which it was open on both sides, five in which it was open 
on the right side, and four on the left. In fifty-three new-born 
infants, Camper found twenty-three open on both sides, eleven 
on the right, and six on the left. Schreger found in thirteen 
infants that the canal was open in eight on both sides. Paletta 
gives the rule, that the complete closure of the vaginal canal 
takes place from the twentieth to the thirtieth day after birth. 

Hernia into the Vaginal Process of the Peritoneum. — When 
the intestines escape into this open canal, the hernia of infancy 
exists, and the serous sheath is converted into a hernial sac. 
Haller, in 1749, was the first to call the attention of pathologists 
to this fact. John Hunter and Percival Pott confirmed his ob- 
servations. Haller called the variety in which the intestines 
and testis touch each other, or are contained in the same sac, a 
" congenital hernia," which name is still applied to it. Birkett, 
however, considers the term inappropriate, since " the hernia 
does not exist either during intra-uterine life or at birth." As, 
however, a congenital malformation allows the descent of a 
hernia soon after birth, Malgaigne calls it the "hernia of in- 
fancy ■." Birkett still, however, prefers the term, " hernia into 
the vaginal jwocess of the peritoneum." See Fig. 10. Other illus- 
trations of the same abdominal imperfection may be found in 
Camper's " Icones Herniarum," John Hunter's " Med. Comm.," 
and in Palmer's edition of the " Works of J. Hunter." 

Pott wrote nearly a hundred years ago that " ruptures of this 
kind are said to be very rare, but from what I have observed 
both in the living and the dead I am inclined to believe that 
they happen much oftener to adults than they are suspected to;" 
while Scarpa says, " It is impossible to turn the bottom of the 



CAUSATION OF HERNIA. 15 

hernial sac upwards in congenital hernia, as may be clone in 
common hernia, leaving the spermatic vessels with the testicle 
in their situation ; for it is not possible in congenital hernia to 
raise and invert the bottom of the vaginal coat forming the her- 
nial sac without raising at the same time and turning upwards 
the testicle and spermatic vessels which are inserted into it. 
Upon which point I cannot mention but with horror the injury 
which, from a want of this knowledge, was practised on the 
celebrated physician Zirhmerniann, from the false persuasion 
under which the surgeon labored, of being able to raise up the 
bottom of the vaginal coat without removing the spermatic 
vessels from their situation, and to tie it at its neck in order to 
prevent the return of the hernia, according to an erroneous and 
already antiquated opinion." 

It is probable, according to Scarpa, that the descent of the 
caecum into the scrotum sometimes takes place in preference to 
that of the small intestine. This may arise from an excessive 
laxity of the union of the caecum with the peritoneum, and a 
weakness of the aponeurosis of the external oblique. If the 
hernia be congenital, it was probably occasioned by the adhesion 
of the testis to the caecum before the descent of the former into 
the scrotum. Wrisberg has several times demonstrated a fascia 
binding the testis partly to the mesentery of the vermiform 
appendix, partly to the caecum, and partly to the ileum. 

Hernia into the Funicular Portion of the Vaginal Process. — 
When an annular constriction of the walls of this vaginal pro- 
cess takes place between the external abdominal ring and the 
testis, the hernia lies in the superior portion before spoken of, 
and is called " hernia into the funicular portion of the vaginal 
process." (See Figs. 11 and 12.) Instances of this constricted 
condition of the sac of an oblique hernia are recorded by Pott, 
Wrisberg, Le Cat, Scarpa, Pelletan, Sir Astley Cooper, and Law- 
rence. 



16 HERNIA. 

Acquired Congenital Form. — The " acquired congenital form 
of hernia'* " encysted hernia of Sir Astley Cooper" or the " infan- 
tile hernia of Hey" (see Fig. 13) are synonymous terms for a 
variety of oblique hernia which also depends upon an abnormal 
state of this vaginal process. In this variety the ventral orifice 
of the sheath is closed, but the canal persists from that point to 
the testis. The parietal peritoneum is slowly pushed into this 
sheath, so that, as Hey says, " the tunica vaginalis is continued up 
to the abdominal ring and encloses th'e hernial sac." From its 
name, one might infer that this hernia is always developed in 
infancy ; such, however, is not the fact. ' Hey's case was an in- 
fant fifteen months old, and Cooper's case was about thirty-one 
years old. The variety is very rare. 

Acquired Hernial Sac. — The more common form of hernia 
is where the viscera have been protruded into the acquired her- 
nial sac, which is, however, distinct from the testis or closed 
vaginal process of peritoneum. (Fig. 14.) Pott believed that 
" common ruptures, or those in a common sac, are generally 
gradually formed ; that is, they are first inguinal and by degrees 
become scrotal ; but the congenital are seldom if ever remem- 
bered by the patient to have been in the groin only." The 
great importance of a knowledge of the anatomical differences 
between these two kinds of hernial sacs is especially demon- 
strated in their surgical treatment. 

Birkett says : " When the surgeons of the last century dis- 
covered that a hernia could pass into the vaginal process of the 
peritoneum and there be in contact with the testicle, they ap- 
pear to have been content, and without further research to have 
assumed this variety to be the only form of hernia dependent 
for its origin upon non-closure of the ventral orifice of this canal 
or upon defective obliteration of the upper part of the vaginal 
process of the peritoneum." 

"We now know that the testis may be wholly shut off from 



CAUSATION OF HERNIA. 17 

every protruding viscus, but that there may yet remain the upper 
portion of the vaginal process in open communication with the 
abdomen at the internal ring. Into this csecal or funicular 
portion of the process, a hernia may protrude and be quite as 
much congenital as the variety ordinarily characterized by that 
term. Malgaigne was the first surgeon to point out this variety, 
its origin and its anatomical relations. There may be two expla- 
nations of its occurrence ; either the parietal peritoneum was 
suddenly pushed down, or else the serous canal existed con- 
tinuous with the peritoneal cavity. The latter seems to be 
the more correct view. 

In this connection I beg leave to insert, as one of the most 
recent theories of the causation of hernia, the following essay by 
Samuel Osborn, F.R.C.S., upon " Phimosis as a cause of hernia 
in infants " : — 

" Having, in my capacity as surgeon to the Surgical Appliance 
Society, to examine many cases of hernia and apply some hun- 
dreds of trusses in the course of the year, the frequency of phi- 
mosis in combination with rupture in infants has struck me 
repeatedly. More especially of late, as I have had no less than 
ten cases within the last month. The phimosis in all these 
cases, I am certain, was the undoubted cause of the rupture, and 
may be thus explained. 

" After the descent of the testicle into the scrotum has been 
accomplished, the vaginal process of peritoneum, through which 
it descended, begins to close and become converted into a fibro- 
cellular cord. But the testicles having but lately descended 
(the left coming down between the seventh and eighth months 
of foetal life, and the right between the eighth and ninth months) 
the uniting medium is but yet young ; and, not being sufficiently 
organized, is easily broken down by any strain thrown upon it. 

"Phimosis occasions that strain from the impediment which it 
offers to the outflow of urine ; for the mechanism of ordinary 



18 HERNIA. 

micturition is effected by the contraction of the muscular coats 
of the bladder and urethra ; but in cases of obstruction to the 
outflow of the urine, extraordinary force is called into action, 
and this is effected by the contraction of the abdominal walls 
pressing upon the bladder, whilst the diaphragm is also, at the 
same time, in a state of tension. By this means pressure is 
exerted over the whole of the abdominal wall; and the aper- 
tures by which the testicles have descended to the scrotum being 
always the weakest points of the abdominal surface, they natu- 
rally give way under the strain thrown upon them. In other 
words, the child, straining to pass his urine, forces the abdomi- 
nal contents downwards upon the weak points at the inguinal 
canals, and rupture on one or both sides results. 

" I would go even still further than this, and say that the 
canal which has been the last to close, or in other words, that 
side on which the testicle was the last to descend, is the side on 
which we usually have the rupture occurring ; and knowing that 
the right testicle is generally the last to descend, we naturally 
find that hernia in infants is also most frequently observed on 
this side. That the rupture occurs on the side on which the 
testicle was the last to descend, is only what one would suppose ; 
for the uniting medium, which is effecting a closure of the canal 
on this side, is not in so advanced a condition of organization as 
on the other side, where the testicle has taken its place prior to 
the other. 

" It is thus easily seen how a single truss frequently produces 
a double rupture. The cause of the obstruction to the outflow 
of urine is still present in the phimosis ; and, one inguinal canal 
being guarded by the single truss, the abdomen gives way at its 
next weakest point, namely, the other inguinal canal, and a double 
rupture is the consequence. Such a result might have been 
prevented by early circumcision. The hernia in these cases is 
generally scrotal, or, if not, it soon becomes so by the wedge-like 



CAUSATION OF HERNIA. 19 

projection of the intestines ; and, whether it be congenital or 
infantile in variety, depends upon the amount of the funicular- 
process of peritoneum which has become converted into fibro- 
cellular tissue, or which has been broken down by the aforesaid 
propulsion of intestine. 

"The operation of circumcision as performed upon young 
children, and which was done in all of the cases of which I 
previously spoke, is both easy of performance and effective in 
its results ; easy of performance, because no sutures are ever 
required, children bear pain well, and the parts are usually 
well in a week or ten days ; it is effective in its results, because 
the hernia then stands every chance of being effectually cured by 
the application of a truss, the exciting cause having been re- 
moved ; and at all events a double rupture is prevented by its 
early adoption. Occasionally difficulty arises in the operation 
when the rupture is very large ; for the penis, buried by the 
projection of the rupture, is represented in such cases by a but- 
ton-hole aperture, and the operation is then more easily effected 
if the rupture be commanded by a double inguinal truss during 
its performance. In conclusion, I would suggest that, whenever 
an elongated or contracted prepuce is present in infants, the 
sooner circumcision is performed the better ; thereby the more 
serious complaint of rupture would be prevented." 

Umbilical Hernia. — Umbilical hernia, properly so called, is 
a disease of infancy. It rarely occurs in the adult, and when- 
ever it does occur we may say either that the beginning of the 
disease had passed unobserved in infancy or else that it had 
occurred in the linea alba either above or below the aponeurotic 
umbilical ring or on one or the other side of it; rarely, as is 
shown on page 39, through the ring. 

It is not until the fourth month of fcetal life that the abdomi- 
nal muscles assume a fibrous form from the umbilicus to the 
pubes ; but the centre of their union in the linea alba becomes 



20 HERNIA. 

depressed and is the part of the aponeurosis that is least resist- 
ant to pressure. A small fossa like a funnel is formed in the 
umbilical ring on the side of the abdominal cavity by compress- 
ing the centre of the umbilicus with the point of the finger and 
at the same time drawing the cord gently outwards. Two 
months after the cicatrization of the umbilicus, this fossa is no 
longer presented ; but, on the other hand, a small tubercle which 
resists pressure and to which the peritoneum very firmly ad- 
heres. 

In process of time the cicatrix of the integuments deep- 
ens and comes in contact with the aponeurotic umbilical ring, 
which is likewise plugged in the centre by the three umbilical 
ligaments and by the urachus ; " these ligaments form a triangle, 
the apex of which is fixed in the cicatrix of the integument, the 
base in the liver, in the two ilio lumbar regions and in the fun- 
dus of the bladder." This triangle acts as an elastic bridle to 
prevent the viscera from protruding through the ring. The 
margin of the ring also is thickened and elastic. From all these 
circumstances, it is easy to see that the danger of the formation 
of umbilical hernia diminishes as the foetus approaches maturity 
and as the infant increases in age ; unless, indeed, external con- 
ditions interfere. 

This variety of hernia, like all other varieties, may be either 
Congenital or Adventitious. The congenital form is found in the 
embryo, in the immature foetus, and in the foetus at full term. 
(See page 49.) The hernial sac contains sometimes a knuckle 
of small intestine, sometimes a prominence formed by the liver, 
and sometimes even the spleen or portion of the large intestine. 
Foetuses born with this disease survive in general only a short 
time, both because they are affected with spina bifida and other 
abnormalities and because the viscera protruded have formed 
adhesions and cannot be completely reduced. The principal 
cause of this congenital disease is probably owing to the slow 



CAUSATION OF HERNIA. 21 

and incomplete development and closure of the abdominal 
muscles. (See Fig. I). 1 

Besides the intestine, there is a very well authenticated 
case by Cabrolius that even the urinary bladder, when there 
has been an obstruction to the outflow of the urine, has 
been raised so high in the abdomen as to form a hernia through 




/ "" Attaehmeup of cord. 

Fig. T. — Congenital Umbilical Hernia. 

the umbilical ring and afterward to open externally in a urinary 
fistula. The urethra was closed by a membrane. The girl hav- 
ing reached the age of eighteen, the umbilicus protruding about 
four inches, an incision was made into the membrane, the urine 
took its natural course, the fistula closed and the tumor disap- 
peared. Probably the protruded viscus had no peritoneal cov- 
ering. 

A similar case occurred in a lady patient of mine from 
Deer Isle, Maine, in 1878. From her umbilical hernia she 
menstruated and micturated. The treatment was to dilate the 
urethra and the os uteri, both of which seemed to be spasmodi- 
cally closed as if by a stricture. Menstruation from the fistu- 
lous opening in the hernia had followed the birth of a child ; 
previous to that time urine and pus only had been discharged. 
After six months' treatment, the urine and menses resumed their 
natural course; the fistulous opening was nearly closed by gran- 

1 See Rare Forms of Umbilical Hernia in the Fetus, by James R. Chadwick. 
Reprint from Vol. I. Gynecological Transactions. Boston, lb7o". 



22 HERNIA. 

ulation, but the hernia still remained. It should be stated that 
I was able repeatedly to pass an ordinary uterine probe through 
the fistula into either the uterus or bladder. Closure was 
brought about by the application of perchloride of mercury on 
the end of the probe. 

Adventitious umbilical hernia in children is the result of the 
combination of several unfavorable circumstances. First, we 
may mention as a cause, the slowness of the contraction of the 
aponeurotic umbilical ring ; difficult labor ; the weak cohesion 
of the divided extremities of the vessels of the cord with the 
cicatrix of the umbilicus and the aponeurotic margin of the 
ring, together with the weakness of the integuments composing 
the umbilical cicatrix ; and the permanent tumescence of the 
abdomen for some time after birth. When these circumstances 
exist, the continual cries and struggles of the infant are suffi- 
cient to protrude the viscera from the umbilicus as the weakest 
part of the abdomen. 

The division of umbilical hernia into the true umbilical and 
into the hernia of the linea alba is not without its value. The 
latter increases more slowly than the former, and is more likely 
from its smallness to pass unobserved, especially in very fat 
persons. It is more common above than below the umbilicus, 
because, as Scarpa thinks, the linea alba from the ensiform car- 
tilage to the umbilicus is naturally broader and less resistant 
than from the umbilicus to the pubes, since the recti muscles 
as they descend constantly converge towards each other. The 
treatment also is more difficult and less satisfactory than in true 
umbilical hernia, probably because the aponeurotic ring has a 
natural tendency to contract, while contraction is not easily 
obtained in the fissure in the weakened aponeuroses forming the 
linea alba. 

Hernia in the Adult — Having considered the formation of 
hernia in fcetal life, we will next consider some of the causes of 



CAUSATION OF HERNIA. 23 

hernia in more adult life. Three theories have been offered 
to account for this complaint ; and as the adoption of one or the 
other of them may influence our judgment as to the curability 
of the disease, we will briefly notice them. First ; the theory 
which has received the support of Warton, Morgagni, Brendel, 
Richter, Benevoli, Rossius, and which is now held by some 
surgeons, is that the immediate cause, especially of inguinal 
hernia, is an abnormal elongation of the mesentery permitting 
such movement of the bowels as to allow their protrusion 
through the openings in the groin under abnormal circum- 
stances. The assumption is that a mesentery of proper length 
would not allow any protrusion of the intestines through an 
opening in the abdominal wall. 

Without recapitulating the arguments opposed to this opinion 
from the able hands of Scarpa (Traite pratique des Henries) and 
of Samuel Cooper (Surg. Diet.), some facts may be mentioned 
which any anatomist may observe, and which tend to support 
the conclusion of the first-named surgeon, that the necessary 
elongation of the mesentery does not precede the displacement 
of the intestine, but is more probably simultaneous with it, and 
that both the elongation and the displacement are dependent 
upon a common cause. 

When the bowels are distended with food or air the whole 
front wall of the abdomen is projected forward. There being no 
vacuum and action and reaction being equal, the pressure is 
equally distributed over the whole of the containing parietes. 
The mesentery is stretched to its utmost. If the sides be sound 
and equally resisting, the whole of the abdominal wall yields 
equally to the pressure and no hernia occurs ; but, if one part be 
weak while another is resisting, that part yields to the pressure 
and a hernia results. The culminating point of the pressure is 
produced by the action of the recti and other abdominal muscles 
antagonizing the downward pressure of the abdomen and the 



24 HERNIA. 

inspiratory action of the lungs. The most likely, as well as the 
most frequent place for the abdominal walls to yield before such 
pressure, is in the aponeurotic structures at the side of the recti 
muscles, especially when the internal abdominal ring is not 
sufficiently strong. 

Often, however, the umbilical opening, which is nearer the 
point of attachment of the mesentery than the openings in the 
groin, yields, and this is especially the case in children. In 
other cases the obturatum forameu, the vagina, or the sciatic 
notch are found to be the weak parts, although they are much 
further removed than the groin from the root of the mesentery. 
These facts lead to the induction that the hernia is dependent 
rather upon the weakened abdominal parietes than upon an 
elongated mesentery. 

There is, moreover, a great variety in the position of the at- 
tachment of the mesentery to the spine. It is thus very com- 
mon to find a great part of the small intestines lying in the 
cavity of the true pelvis between the bladder and rectum. 
The same result may also be brought about by hypertrophy of 
the liver, stomach, or spleen ; yet hernia is by no means the 
necessary or frequent accompaniment of these conditions, because 
the abdominal walls may be everywhere equally resistant and 
strong enough to retain the viscera. If then the mesentery be 
long enough to allow the small intestines to lie in the true 
pelvis, it is surely long enough to allow them to protrude at the 
groin if the parietes be weak. 

Again, the direction of the mesentery is toward the left side 
of the abdominal cavity, and the small intestines lie chiefly in 
the left lumbar, iliac, and hypogastric regions. If the supposi- 
tion in question were true, hernia should be more common on 
the left than on the right side, whereas precisely the opposite is 
the case (see page 47). 

But perhaps the most conclusive argument is to be drawn 



CAUSATION OF HERNIA. 25 

from the fact that we find hernia most common, not in subjects 
who have elongated mesenteries, but in those in whom the 
abdominal parietes are deficient or insufficient, and that it is 
an indisputable fact that hernias have been cured by strengthen- 
ing these containing parietes. If hernia were primarily and 
principally due to an abnormal elongation of the mesentery, 
any attempt to cure it, by occluding the opening and strengthen- 
ing the wall, must be either useless or result in a protrusion in 
some other weakened part. 

Second ; — the theory that the chief cause of a hernial pro- 
trusion is to be found in a deficiency in some part of the walls 
containing the intestines. What the precise structure of the 
retaining power is, is a matter upon which there is a difference 
of opinion. Some suppose that the parietal peritoneal layer is 
the most powerful agent in retaining the intestines. At the 
internal abdominal ring there are evident traces of a cicatrix 
closing the vaginal process and the canal of Nuck. This must 
evidently offer considerable resistance to a protrusion. The 
sense of something giving way, which is often one of the first 
experiences in the occurrence of a hernia, is probably due to the 
yielding of this resistance, together with the forcible dilatation 
of the internal rinsr. 

o 

Although weakness and laxity of the peritoneum, together 
with a general laxity in the abdominal muscles, may predispose 
to the formation of a hernia, yet it can hardly be maintained 
that this is the chief cause of hernia, since hernia frequently 
occurs where no such laxity exists. 

The chief cause of rupture, according to this theory, consists 
in the inefficiency of the tendinous or muscular walls to resist 
pressure from within. The cause of inguinal hernia lies in the 
failure of the valvular action of the walls of the canal, as we 
have previously shown ; of femoral, in the inefficiency of the 
cribriform fascia, which is protruded to form the fascia propria 
of the hernia. 



26 HERNIA. 

Third ; — the theory that the causation of hernia is to be 
found in an increased pressure caused by the viscera. This 
increased pressure may be termed the exciting cause, while the 
diminished resistance of the abdominal walls is the predisposing 
cause of hernia. The action of the respiratory muscles is the 
principal source of pressure upon the viscera. The diaphragm, 
by its contraction, pushes the contents of the abdomen against 
the relaxed abdominal walls ; these subsequently contract and 
push the viscera against the relaxed diaphragm. 

When these movements of diaphragm and abdominal muscles 
are alternate, the viscera can easily sustain the pressure and 
compression. When, however, these same muscles act simul- 
taneously, as during the forcible expulsion of the contents of 
the uterus, rectum, or bladder, or when they are firmly fixed to 
enable the person to perform any great exertion, the viscera sus- 
tain a much greater compression, and consequently react much 
more violently upon the abdominal muscles. The strength of 
the walls, and the pressure of the viscera are so admirably 
adapted to each other in their normal state, that, with ordinary 
respiration and with the ordinary contraction of the abdominal 
muscles, the viscera do not protrude. When, however, the walls 
are abnormally weakened or the action of the muscles excessive, 
the resisting power of the former is often overcome, and a hernia 
is produced. When the viscera are once displaced, if the weakest 
point of the abdominal walls is at the groin, their further dis- 
placement is very rapid, owing both to gravity and the action of 
the diaphragm and abdominal muscles. 

The predisposing causes of hernia are of three kinds : — First : 
Whatever tends to dimmish the resistance of the abdominal 
walls, such as a weakened constitution, laxity of the fibrous 
tissues, congenital enlargement of the canal, ascites, pregnancy, 
old age, etc. Poverty and hard work thus favor the production 
of hernia. Men, who have larger abdominal rings than women, 



CAUSATION OF HERNIA. 27 

are the more liable to inguinal hernia ; while women who have 
a deeper and wider femoral arch than men, and usually smaller 
muscles over the space, are relatively more subject to femoral 
hernia. 

Second : Whatever increases the volume, weight, or mobility 
of the contained parts ; such as hypertrophy of the viscera from 
whatever cause, deposition of fat in the omentum, etc. 

Third : The existence at birth, and persistence, afterward, of a 
canal composed of a prolongation of the peritoneum. This has 
already been considered on page 13 under congenital hernia. 

The exciting causes of hernia are : — First : Wounds or lacera- 
tions of the abdominal walls. Second : The weakening or 
destruction of the same parts by inflammation. Deep-seated 
abscesses about the hip-joint, groin, and perinseum, may also 
undermine and weaken their adjacent tissues. The aetiology 
of ischiatic and pudendal hernia, together with some other 
varieties, will thus be easily understood. Third : What- 
ever diminishes the capacity of the abdominal cavity, the viscera 
remaining of their normal size. Under this head may be in- 
cluded the tight lacing of corsets, the wearing of tight pantaloons 
or a strap around the waist, as is the custom among many laborers. 
Fourth : The gradual expulsion of the parietal peritoneal mem- 
brane at weak parts of the abdominal walls. This protrusion is 
produced by whatever calls into play the violent simultaneous 
action of the diaphragm and the abdominal muscles. 

This action, which constitutes the act of straining, plays an 
important part in the production of hernia, even when the 
containing parietes possess their usual strength. It is most 
strikingly exemplified in lifting heavy weights, leaping, singing, 
especially in deep tones, and in playing on wind instruments ; 
in the powerful and irregular acts of excessive coition, vomit- 
ing, coughing, horseback riding, and some military exercises ; 
in certain diseases, as calculus, constipation, asthma ; in exces- 



28 HERNIA. 

sive exertions immediately after a full meal, or during the state 
of pregnancy, in the exertions attending difficult parturition, 
and in the forcible attempts to evacuate the rectum or bladder 
made by persons afflicted with stricture, enlarged prostrate, 
stone in the bladder, and constipation. 

Straining is also produced by haemorrhoids, or piles, by fis- 
sures of the anus, and by fistula in ano. Spondylitis, and 
curvature of the spine from whatever cause, may also produce 
a protrusion of viscera at weak or weakened portions of the 
abdominal parietes. Hernia may however be produced, not 
only by these diseases themselves, but also by the very 
methods of their treatment. Prof. John T. Hodgen, of St. 
Louis, recognizing this fact, criticised, at the Eichinond meet- 
ing of the American Medical Association, the plaster casts 
applied by Dr. Lewis A. Sayre for curvature of the spine. 
He believes that they "have a tendency to cause hernia and 
deprecates their use in such cases." 1 Certain concussions, for. 
example, those from railroad accidents and collisions, will also 
be found to be a fruitful source, of hernia. 

In this connection, the essay upon phimosis as a cause of 
hernia in infants, on page 17, will be interesting for the reader 
to peruse again. Generally, several causes act concurrently in 
the production of hernia. Some authors have gone so far as to 
, assert that a hernia cannot be produced in a person who is not 
predisposed to it. This would seem to merit some consideration, 
when we reflect upon the cases cited by different authors and 
met in our own practice, where a hernia, being retained, was 
followed by a second, and sometimes by even a third or fourth, 
in other weakened parts. 

Consistently, however, to support the opinion that exertion is 
the most frequent cause of hernia, it must be shown that exer- 
tion is the primary as well as the proximate cause. If a person 

during some extraordinary exertion suddenly experienced great 

1 See p. 20G. 



CAUSATION OF HEKNIA. 29 

pain in the groin, and was sensible that something unusual had 
occurred ; if on examination a protrusion of the viscera was 
found, but the parietes in a firm state and the ring so constrict- 
ing the protrusion as to occasion some difficulty in replacing 
the tumor ; and if, when replaced, it did not again immediately 
protrude, a fair argument would be that up to the time of the 
accident there was no predisposition to hernia, but that over- 
exertion was the sole cause. 

On the contrary, suppose a person sensible of a hernia dur- 
ing great exertion, but the parts found to be in a relaxed state, 
the protrusion, not constricted by the ring but readily reducible, 
and when reduced disposed to reprotrude immediately, — in fact 
the resistance of the parietes diminished ; how can it be ascer- 
tained whether in such a case exertion or predisposition was 
the remote cause ? 

That extraordinary exertion is often a cause of hernia, no one 
who has had any experience with the complaint can doubt, and 
that it will facilitate the descent of the viscera, when a predis- 
position exists, is also certain. Still, it is a well-known fact that 
indolence and sedentary habits encourage such a predisposition, 
and I do firmly believe that if an impartial investigation were 
made, the complaint would be found quite as common among 
those who lead sedentary lives as among those of more active 
habits. Persons of sedentary habits are not only more liable to 
the predisposing causes in a greater degree, but they are also 
equally liable to many of the exciting causes. 

The wear and tear of a working man's constitution is often 
erroneously attributed to the quantity of exertion employed in 
gaining a subsistence. A little inquiry and observation will 
correct this notion and enable us to find other and much more 
probable causes, among which intemperance stands pre-eminent. 
The frequent draughts of ale and beer, to say nothing of stronger 
liquors, to which most working men are accustomed, are of 



30 HERNIA. 

themselves sufficient to account for most of their ailments. 
Those men whose work is what is -termed heavy find a ready 
excuse for such indulgences ; they foolishly imagine, or pretend 
to imagine, that all these potations are necessary to support 
their strength, while the artificial thirst thus created by habit is, 
they contend, the call of nature. The natural vitality of the 
body, which is so powerful an auxiliary to the vis medicatrix, is 
therefore turned to no other account than partially to resist the 
effects of this inseparable intimacy between the cup and the 
mouth. 

The thousands who are employed in manufactories, some 
exposed to fever temperature, some to the noxious effects of 
impure air, some to unwholesome employments, some only 
half fed, and almost all packed into rooms ill-ventilated, and 
living in the same unhealthy manner, furnish abundant evidence 
of causes for debility without referring to excessive labor. An 
eminent physician has said that ere long cases of hernia would 
become comparatively rare because machinery would be univer- 
sally substituted for manual labor. We know that within the 
past fifty years machinery has been most extensively introduced, 
and therefore less manual labor required; yet hernia has not 
become less frequent, but on the contrary much more frequent. 
This is shown by the extraordinarily increased demand for 
trusses, according to the statistics given by various truss socie- 
ties and manufacturers. 

Lawrence has said that our inferiority in muscular develop- 
ment arises, not from organic deficiency, but from want of 
exercise. Civilized man is ignorant of his own powers. He is 
not sensible how much he is weakened by effeminacy, nor to 
what extent he might recover his native powers by the habitual 
and vigorous exercise of his frame. Labor braces muscular 
fibre by promoting full circulation and healthy perspiration. 
It is true that labor carried to excess produces fatigue; but rest 



CAUSATION OF HERNIA. 31 

and conservative power restore strength again, and it is reasona- 
ble to suppose that this restorative power is not denied to the 
parts in the neighborhood of herniae. The amount of exertion 
necessary to cause fatigue must, of course, depend upon habit 
and constitution, but, at all events, it is quite certain that the 
less we exercise ourselves, the sooner we are fatigued. 

" The first physicians by debauch were made ; 
Excess began, and sloth sustains the trade : 
By chase our long-lived fathers earned their food, 
Toil strung the nerves and purified the blood, 
But we, their sons, a pamper'd race of men, 
Are dwindled down to three score years and ten ; 
Better to hunt in fields for health unbought, 
Than fee the doctor for a nauseous draught ; 
The wise for cure on exercise depend — 
God never made his work for man to mend." 

Dryden. 

If then sedentary habits occasion great relaxation, the parts 
in the groin will necessarily become more flaccid, and we may 
expect to find the rings larger, their margins weakened, and, in 
all probability, an abnormal laxity of the peritoneum. Such a 
condition of the parts is a positive predisposition to hernia, and 
it requires only some exciting cause, to which all are liable, to 
force the viscera out of the abdomen. On the contrary, if the 
result of exertion shall be strength of muscle and tension of 
fibre, the parts in the groin will be capable of offering consider- 
able resistance ; supposing, of course, no malformation to exist. 

" In the development of inguinal hernia," says Wood, " there 
are at least three different conditions of individual peculiarities." 
In one class of cases, the muscular system is well developed. 
The cremaster is powerful, the hips are narrow, the inguinal 
canal and Poupart's ligament short, and the genital organs small. 
The hernia is frequently direct, sometimes separating the fibres 
of the outer pillar. The sac is small in diameter, but when 



32 HERNIA. 

scrotal, much elongated and with a flask-shaped neck ; the 
fundus is apt to become pyriform and, if irreducible, to simulate 
a hydrocele. 

The subjects of such hernias are able-bodied men, soldiers, 
sailors, or laborers. Their hernia occurs suddenly with a sense 
of something giving way, and is often accompanied with pain 
and sickness. These cases are liable to that violent form of 
strangulation which depends upon a spasmodic contraction of 
the internal oblique across the neck of the sac. 

The second class of cases has a greater development of the 
fibrous and fascial structures, with less development and power 
of muscle. Such persons are wiry and sinewy, so called, and 
often have a loose and shambling gait. The pelvis is large and 
the inguinal canal and Poupart's ligament consequently long. 
The muscular portions of the abdominal muscles are small in 
proportion to the extent, and thickness of their aponeuroses. 
The total effect of this arrangement of the muscles and aponeu- 
roses is to depress the abdomen in the median line and to 
produce extensive projections towards the iliac wings. 

The genitals are usually large and loose, with a pendulous 
scrotum indicating an abundance of fasciae and a feeble de- 
velopment of the muscular fibres of the clartos. The tendons 
are thick but inelastic, and apt to be weakened by rheumatic 
changes or fatty degeneration, especially after middle life. 
The pillars of the external ring are thick, but lose themselves 
in the thick coverings of the hernial sac, so that their edges 
are less evident to the touch. The hernia is usually of the 
oblique variety, and of slow formation. It is noticeable that 
a thick gristly ring is apt to form in the substance of the sac at 
its neck, while thickened bands of the deeper fascia may also 
cause a strangulation. This variety of hernia is a favorable 
one for the radical cure. 

The third class of cases retains many of the foetal peculiarities, 



CAUSATION OF HERNIA. 33 

and is generally of congenital or infantile origin, the viscera 
protruding from imperfect abdominal muscular development. 
The patient is usually fat, and the inguinal rings very patulous 
and capable of easy dilatation. The pillars of the external ring 
are small and thin, and are not so easily made out as in the 
former cases, being gradually lost in the coverings of the sac. 
They are weak and easily torn. The inguinal canal is short 
and wide ; the internal ring large and its edges not easily dis- 
tinguished. For a further description of them, see page 14. 

Femoral Hernia. — A few special words upon this variety 
seem to be necessary. Before the age of twenty, this hernia 
is extremely rare. Sir Astley Cooper saw only three cases, aged 
seven, eleven, and nineteen respectively. M. Malgaigne, during 
five years of service at the Bureau Central, did not see a single 
case affected before the age of twenty. It is universally ad- 
mitted to be more frequent in females than in males (page 44), 
and on the right than on the left side. There should, how- 
ever, be one exception to this general statement. Malgaigne 
asserted that inguinal hernise in females are the more numerous. 
He admits that femoral hernia is most frequently the subject 
of operation in women, but this, he says, proves only that 
femoral is more liable than inguinal to strangulation. See, 
however, page 43. He therefore established a more accurate 
method of diagnosis, which may be found on page 342. 

The greater predisposition to femoral hernia in the female may 
be attributed to the fact that the muscles filling and covering 
the femoral arch are smaller in them than in men, and because 
the arch itself is wider and deeper from the wider expan- 
sion of the iliac wings. In the male, the arch, being smaller, is 
compactly filled by the psoas and iliacus muscles, and by the 
vessels and nerves passing to the thigh. It is also protected by 
the strong union of the transversalis and iliac fasciae. The 
shrinkage of these muscles in advanced age leaves the femoral 



34 HERNIA. 

arch less occupied, and when added to the general muscular and 
fibrous relaxation predisposes to the formation of femoral hernia. 
Hence is readily explained the greater frequency of this kind of 
hernia in old persons of both sexes. 

The direction of the crural ring being very nearly upward 
and downward, the weight of the abdominal viscera, and the 
pressure exerted upon them by the abdominal muscles, com- 
bine in their effect to push upon the peritoneum and septum 
crurale which cover the ring above. When, therefore, the ring 
and canal are wide, as we have said they are in the female, 
the action of any exciting cause will tend to produce a femoral 
hernia. It will be found also that in those males who are the 
subjects of femoral hernia the pelvic wings are broad and spread- 
ing as in the female, and that, moreover, the muscular develop- 
ment is less than is normal to the sex. 

Among the exciting causes of this variety of hernia may be 
included, not only all the exciting causes that we considered on 
page 27, such as lacerations, inflammations, compression of vis- 
cera, and straining, but also the more especial exciting causes, as 
dropsy, tumors, accumulation of peritoneal fat, the violent ab- 
dominal exertions attending child-birth, and the general relaxa- 
tion of the abdominal walls after pregnancy. 

The influence of pregnancy and child-birth upon the produc- 
tion of femoral hernia is so marked that it is rare to see this 
variety except in women who have borne children. In males, 
abdominal distention or accumulation of fat acts chiefly upon 
the inguinal rings, both because they are kept open by the 
spermatic cord and because the increased pressure acts upon 
Poupart's ligament from above. Femoral hernia has, however, 
been known to co-exist with inguinal. Malgaigne has noticed 
such a complication ; Lawrence mentions a preparation in St. 
Bartholomew's Hospital, " exhibiting an oblique inguinal and a 
femoral hernia on each side in a male subject ; " while Teale 



CAUSATION OF HERNIA. 35 

cites a case of a patient admitted into the Leeds Infirmary " with 
two inouinal and two femoral herniae." 

The first occurrence of a femoral hernia is due to the yielding 
of the peritoneum, and to the loosening of its connections at the 
upper margin of the crural sheath. A pouch is then formed at 
the expense of the neighboring folds or false ligaments of the 
bladder. This then presses upon the thin septum crurale, until 
finally the cribriform fascia is stretched, the saphenous opening 
dilated, and the fundus of the tumor emerges under the integu- 
ments of the thigh. If these tissues be resistant, the hernia may 
remain for some time like a bubonocele and cause no visible 
tumefaction, being concealed by Poupart's ligament and the fal- 
ciform process. 

When, however, the integuments have yielded so that the 
hernia has protruded beyond the crural canal, the tumor gradu- 
ally expands into a globular form, while the neck remains of 
nearly its original size ; it has been known to extend half-way 
down the thigh. Serous cysts are occasionally developed in 
its vicinity, from the closure of the neck of an old hernial sac 
and from a new protrusion taking place by its side. For the 
differential diagnosis of femoral hernia, see Table No. 2, page 79, 
and also page 341. 

Effects of Hernia. 

On the other hand, whatever be the individual physical pecu- 
liarities, we may naturally expect to see certain constant effects, 
when once there has formed a hernial protrusion. In a small 
and recent hernia that Can be easily reduced, the protruded vis- 
cera seldom exhibit any change of structure ; when, however, 
the hernia has attained great size, has long existed, and has 
become irreducible, they are frequently found congested, opaque, 
indurated, or hypertrophied. The coverings of the sac may also 
undergo pathological modifications (see page 74), while the 



36 HERNIA. 

mesentery contained in the sac may be thickened, loaded with 
fat, and filled with congested and varicose vessels. 

Under the distending influence of a protruded mass, the hernial 
apertures, which at first are somewhat oval, gradually become 
enlarged, and assume a more circular form. This enlargement 
is generally effected by the elongation and separation of the 
aponeurotic fibres composing the pillars of the rings. We have 
already seen (page 7) that the apertures are sometimes displaced 
in old hernise, so that the internal and external rings finally lie 
in close apposition, as they did in the foetal state. Scarpa has 
noticed another displacement of the tendinous fibres of the ex- 
ternal ring in large scrotal herniae. " The superior pillar is forced 
so much upward and forward that the neighboring tendinous 
bands are made to approach each other, and are thus gathered 
together at the upper part of the ring, so as to give to it a degree 
of thickness and hardness much greater than it naturally pos- 
sesses." 

Finally, the effects of a hernia may be constitutional. The 
functions of the alimentary canal may be disturbed, causing 
nausea, flatulence, indigestion, and constipation. When the omen- 
tum has been protruded, there may result an injurious traction 
upon the stomach and colon, painful, dragging sensations, and 
not infrequently colic. Hence it is not uncommon to see per- 
sons afflicted with hernia become emaciated, and show weariness, 
exhaustion, and even suffering, from comparatively slight exer- 
tions. " In fact, the healthy performance of the nutritive proc- 
esses is so much interfered with as to render them insufficient 
to compensate for the waste constantly taking place in the 
tissues." 



CHAPTER II. 
Hernle : Kinds and Frequency. 

kinds of hernle. 

The varieties of Hernias as generally described derive their 
names from the time of life at which the hernial sac is formed, 
from the region of the body which is affected, from the viscus 
composing the protrusion, or from the condition in which their 
contents are formed. 

As regards the time of life at which Hernias may be found, 
we recognise Congenital, occurring either at time of birth or 
immediately thereafter ; with its variety, the Infantile or 
Encysted Hernia ; the former relating to the complete openness of 
the vaginal sheath of the tunica vaginalis, and the latter, the 
encysted, to the closure of the sheath at the abdominal parietes 
leaving a cavity below inclosed by the tunica vaginalis ; 
Accidental, from whatever cause, whether undue exertion or 
severe injuries; and Hernia? as the result of weakness of the 
abdominal tissues. 

Hernias named from the region of the body in which they 
occur may be 

Cerebral. — This term is applied to several different forms ; one 
form may be due to a defect in the cranial ossification, another 
to a congenital deficiency of both cranium and integuments 
resulting in the speedy death of the infant, while a third form 
is seen as a result of the operation of trephining. 



38 HERNIA. 

Diaphragmatic or Phrenic. — These are somewhat iare, often 
congenital, and when strangulated are beyond operative means 
of relief. The part of the diaphragm where the fibres are 
especially weak and deficient is "between the sides of the 
muscular slip from the ensiform appendix and the cartilages of 
the adjoining ribs." 1 

Umbilical, Exomphalos, Omphalocele, or Ruptured 
.Navel. — These are more frequent in infants. When in adults 
they are more common in females than in males and in obese 
than in spare persons. 2 They protrude through the opening left 

1 They are of three kinds : — 1st, where the muscular fibres of the 
diaphragm lose tone, so that the abdominal viscera are pressed into the 
thorax ; 2ndly, where there is a congenital defect in the fibres ; and 
thirdly, where the hernial tumour protrudes through one of the natural 
openings in the diaphragm which have been stretched. 

2 To illustrate some of the remarkable displacements in the thoracic 
and abdominal cavities that may result from this variety of Hernia, I make 
the following quotation from the Proceedings of the St. Louis Med. Society 
of a rather unique case. The report was made by Dr. Stevens :— 

HERNIA OF THE TRANSVERSE COLON. 

" I report this case from notes taken at the time of my observations. I 
was called by Dr. John Laughton to make the dissection in an examination 
of the body of Police-officer Holton. Besides Dr. Laughton, who had 
been the attending physician, there were present Dr. Thompson and Prof. 
Ellsworth Smith. About a year before death, and while in the perform- 
ance of his official duty, Holton received a stab, made with a pocket knife. 
The wound was on the left side between the eighth and ninth ribs and 
about four inches from the sternum. The wound healed readily and with- 
out any alarming complications. After a few days, just at the site of the 
wound, there appeared a soft reducible tumour, about the size of half a 
hen-egg but causing no inconvenience. He returned to his occupation 
and continued to perform his duties for several months; in fact, till 
within a few days of the time of his death. The death was caused by 
enteritis and was not attributed to the lesion mentioned. In the long 
interval between the time of the injury and his death the case excited 
considerable interest and there was a wide difference of opinion as to the 
nature of the tumour, the majority believing it to be a Hernia of the 
lung ; only one or two, as the sequel demonstrated, formed a correct 
diagnosis, viz : A Hernia of the transverse colon. 

" Upon opening the cavity of the chest a most remarkable displacement 



HERNLE: KINDS AND FREQUENCY. 39 

by the umbilical vessels of the foetus. 1 The visci found most fre- 
quently protruding are the epiploon or omentum, the jejunum, 
the arch of the colon and sometimes the stomach. The tumour 
is usually round, readily reducible and not very liable to strangu- 
lation. In the foetus the Opening left by the umbilical vessels is 
perfectly patent but in the adult the aperture is so firmly closed 
that it is stronger than the linea alba itself. The linea alba 
however shows even in the normal state weak places around 
the vessels as well as various orifices in the tendinous parietes 
for small cutaneous blood-vessels. When from any unusual 
strain, as from pregnancy, these openings have yielded and 

of thoracic and abdominal viscera was apparent. The stomach with its 
greater curvature upwards, was the first object in view ; the left half, at 
least, of the transverse colon was above the plane of the diaphragm ; the 
heart was found backward from its normal position, and the lung 
diminished by at least four-fifths of its usual dimensions driven to the 
extreme upper part of the cavity, and presenting more the appearance of a 
spleen than of a lung. It was wholly impervious to air. The right lung 
seemed to have expanded and have forced the mediastinum to the left of 
its normal location. The diaphragm of that side seemed to have almost 
disappeared ; only a vestige remained showing its marginal attachment. 
You will readily form an idea of the enormous distension that had taken 
place in order to admit the passage upward of nearly the whole of the 
stomach and a large section of the colon. 

"This then was the state of things as revealed by the autopsy. Our 
conclusions were as follows : That the knife first passed through the in- 
tegument and intercostal structures, entering the pleural cavity during the 
act of expiration, the lung escaped injury ; the blade then passed through 
the diaphragm without wounding any viscus beneath ; that at first, a 
small section of either the colon or the stomach entered the opening in 
the diaphragm, and then by slow advances, so slow in fact as not to bo 
perceptible to the individual himself, and so slow that the natural functions 
of the various organs implicated had ample time to conform their com- 
pensatory or other actions to the gradually changing relations. Probably 
it took weeks or months to work out the entire revolution. 

" A rather interesting fact was mentioned by the attending physician, 

that the patient frequently vomited during his illness. Of course this 

must have been performed solely by the contraction of the muscular fibres 

of the stomach and without the action of the diaphragm and abdominal 

muscles." 

1 See p. 19. 



40 HERNIA. 

become enlarged in adults, the protrusion of the viscus may be 
and often is called umbilical because near the umbilicus. 

Thyroid. — In this variety the protrusion of the abdominal 
viscera comes through the thyroid or obturatum foramen. 

Ischiatic. — Protrusion through the sacro-sciatic notch. 

Vaginal. — When the tumour descends along or into the 
vagina. 

Perinatal. — When the protrusion is through a laceration of 
the perineum of the male. It is the counterpart of the vaginal 
in the female. 

Lumbar. — Of this variety a very few rare cases have been 
reported by Petit and Cloquet. The intestine is protruded 
through the posterior muscles immediately above the pelvis. 

In the anteriw region of the abdomen we have Inguinal and 
Femoral, the former protruding above and the latter below 
Poupart's ligament. 

Of Inguinal Hernia there are two varieties. 

External or Oblique. — Called external because the neck of 
the sac lies on the outer or iliac side of the epigastric artery. 
The intestine emerges through the internal abdominal ring, 
pushing before it a pouch of peritoneum, and then lies in the 
inguinal canal. " Pursuing the oblique direction of this canal, 
it emerges at the external abdominal ring, and enters the scrotum, 
into which it descends. The mouth of the hernial sac is situated 
to the outer side of the internal epigastric artery, whilst its neck 
and body are usually in front of the structures composing the 
spermatic cord. But in rare cases these organs are divided ; 
sometimes the blood-vessels pass over the tumour, the vas 
deferens behind it, and vice versa ; or they are attached to the 
sides of the tumour. The relative positions of the hernial tumour 
and testicle differ. The variable site of this latter organ depends 
upon congenital defect, and hence in some cases the testis 
cannot be distinguished from the tumour produced by the hernia. 



HERNLE : KINDS AND FREQUENCY. 41 

However, in the majority of cases the testicle is situated at the 
posterior and inferior regions of the scrotum ; more rarely, it 
may be detected at the front of the fundus of the tumour. An 
endeavour should always be made to ascertain the site of this 
organ, in every case of Inguinal Hernia, and under all circum- 
stances." * 

Internal or Direct. — Not so common a form as the oblique. 
It pushes through some part of the abdominal wall internal to 
the epigastric artery, i.e. on the pubic side of it, and passes 
directly through the abdominal parietes and external ring. 
" The mouth of the sac is close to the outer border of the 
pubic attachment of the rectus muscle, the posterior surface of 
which may be more easily felt when the Hernia is reduced than 
in the oblique variety." "The finger enters the abdominal 
cavity much more readily in the direct furm of Inguinal Hernia 
than in the oblique. In its passage from the abdomen it 
traverses merely that small portion of the inguinal canal which 
lies immediately behind the external inguinal ring, and those 
structures which form that part of the floor of that caual are 
either pushed before the Hernia, or they are lacerated when 
the hernial sac escapes through the opening so formed. Those 
structures are the conjoined tendons of the internal oblique and 
transversalis muscles and the pubic portion of the internal 
abdominal fascia. The spermatic cord and round ligament are 
not attached to the hernial sac until it has reached the external 
abdominal ring. When it has passed that point, they lie to its 
outer side, and are usually less identified with its tissues than 
in the oblique variety.' ' 2 

A rare anatomical variation is when the tumours pass not 
through the true external abdominal ring but through a division 
of the fibres of the external abdominal muscle near the ring. 

Bubonocele. — When an indirect or oblique Inguinal Hernia 

i Beckitt. 2 Ibid. 



42 HERNIA. 

is incomplete, i.e. not fully formed or protruded, it is called a 
Bubonocele, probably from its resemblance to an inflamed 
lymphatic gland in the groin (bubo). 1 

Scrotal or Oscheocele and Pudendal. — When a complete 
Inguinal Hernia passes through the external ring and escapes 
into the scrotum it is called Scrotal, when into the labia majora, 
Pudendal. 

Ventral. — When it escapes through some part of the ab- 
dominal walls usually strong and muscular it is called Ventral 
Hernia. 

Ventro-Inguinal. — When a Ventral Hernia slips into the 
inguinal canal it is called Ventro-Inguinal. 

Femoral, Crural or Merocele. — This form of Hernia was not 
accurately differentiated from Inguinal until the middle of the 
seventeenth century, and its exact anatomical relations were not 
properly understood or described for many years after. 1 It pro- 
trudes through the femoral or crural ring, the upper opening 
of the crural canal in the angle formed by Gimbernat's and 
Poupart's ligaments, and emerges from the saphenous opening 
of the fascia lata in the upper and inner side of the thigh, the 
femoral veins lying on the outer side of the ring, and the 
epigastric artery crossing the upper and outer angle of the ring. 
It is more common in females than in males. 

As regards the contents of the sac or the viscus composing 
the protrusion, if it be intestine, usually the small intestine and 
more particularly the ileum, we have an Unterocele, if omentum 
we have an Epiplocele, while a combination of the two is called 
Entero-EpiploceU. Earer forms of hernial tumours from the 
abdomen are Gastrocele, 2 Hepatocele, 3 and Cystocele, 4 protrusions 
of stomach, liver, and bladder. 

The terms applied to the pathological conditions in which we 

1 It has passed through the internal ring- but not the externa], therefore 
it lies in the inguinal canal. 



HEENLE: KINDS AND FREQUENCY. 43 

find Herniae are Reducible when the protrusions can be readily 
returned to the abdomen. 

Irreducible, a generic term to signify a Hernia that cannot be 
returned either because of adjoining adhesions, incarceration, 
strangulation, thickening of coverings or deposit of fat. 5 

Incarcerated, when the Hernia has become temporarily irre- 
ducible because of a constriction in the intestines which prevents 
passage of faeces. 6 

Strangulated, when the Hernia is irreducible because of a 
constriction which prevents not only passage of fasces but also 
circulation of blood in the tumour. This circulation may be 
impaired u by muscular spasm, oedema or the sudden foicing 
of additional contents into the sac." For the relief of this 
form of hernia, the operation of herniotomy or kelotomy must be 
employed. 7 

FREQUENCY OF HERNIA. 

The frequency of the occurrence of Hernia varies in different 
kinds of hernias according to kind, sex, age, population, occupa- 
tion, walls of the abdomen, social state and the nationality. 

1. Relative frequency of the different Kinds. — The In- 
guinal and Femoral are the most frequent, and after them 
comes Umbilical, while all the others can be considered as 
very rare. Out of the 93,355 Herniae forming the total of the 
statistics published in 1855 by Bryant, we find 46,551 simple 
Inguinal to 7,452 Femoral without distinction of sex, being 
1 Femoral to 624 Inguinal. Of 30,575 double Herniae there 
were 28,503 Inguinal and 1,972 Femoral which gives the 
relation of 1 double Femoral Hernia to 14 '25 double In- 
guinal. The sum of these figures gives 75,054 simple and 
double Inguinal to 10,425 simple and double Femoral, being 
1 Femoral to 7*19 Inguinal. These figures may not form 
an absolute rule, but still the result of 93,355 cases ought 



44 HERNIA. 

to be some guide to the relative occurrence of these kinds 
of Hernias. 8 

2. Relative frequency according to Sex. — J. Cloquet 
states the relation of this occurrence as 2 males to 1 female. 
According to Malgaigne it is 4 males to 1 female. The tables 
prepared by the Truss Society of London give still different 
results, being 5 males to 1 female. According to Kingdon 
this last proportion is too great, leaving the relation given by 
Cloquet as nearer the truth. As regards the relative occur- 
rence of Inguinal and Femoral Hernias in the two sexes the 
Truss Society in 1855 claim about 1 Femoral in the male to 
75 Inguinal, but in the Eeport for 1863 give 1 Femoral 
to 32 Inguinal. It is so hard to understand such a difference 
in these figures that only a general idea must be drawn from 
them. According to the same Eeport of 1855 the relation 
in the female is 1 Inguinal to 4*6 Femoral, while according to 
Malgaigne Inguinal are even more numerous than Femoral 
in the female, although proportionally less than in the male. In 
the Eeport of 1863 the proportion was not quite 1 Inguinal to 
1*04 Femoral in the female, figures which seem a priori much 
more reasonable. 

As regards Umbilical Hernias, they are more frequently 
found in the female than in the male. 

3. Frequency according to Age. — In 300 Hernias examined 
by Malgaigne 

26 occurred between the ages of 10 — 20 

45 „ „ „ 20—30 

66 „ „ „ 30-40 

163 „ „ „ 40—80 

300 

4. Frequency in Relation to Population. — According to 
the same authority above cited — 





HEI1NLE : KINDS AND 


frequency. 




Before 1 year 


there is 1 Hernia in 


every 21 individuals. 


From 


1— 2 


»> •*■ 


II 


29 


ii 


n 


2— 3 


i> *■ 


II 


37 


i> 


a 


5—13 


it ■*■ 


II 


77 


ii 


To 


20 


» ■*■ 


l> 


32 


ii 


» 


28 


t> *• 


II 


21 


ii 


From 30—35 


t> •*■ 


II 


17 


ii 


» 


35—40 


11 -*• 


l> 


9 


ii 


At 


50 


11 ■*• 


II 


6 


ii 


n 


60—70 


» J- 


l» 


4 


** 


» 


70—75 


>i -*■ 


II 


3 


»» 



45 



He estimates the proportion of the whole population of 
France which is ruptured to be 1 out of every 13 males, and 
1 out of every 52 females, or taking both sexes together 1 
out of every 20*5 individuals. 

5. Frequency according to Occupation. — In a general way 
we may say that the more difficult the occupation the more 
liable are those engaged in it to suffer from Hernise. Here 
as in all other tables of a similar nature, figures can be only 
approximately valuable and must not be relied upon as 
absolute. The following table I believe to be as nearly 
accurate as can possibly be. 



46 



HERNIA. 



Report of Kingdon (Truss Society). 



According to Census of 1S51. 


i 

1S59. 


1S60. 


1861. 


Farm labourers .... 




171 


173 


Farmers .... 






776 


503 


734 


Boot and Shoemakers 






c8 


53 


12 


Carpenters and Joiners . 






173 


178 


99 


Tailors ..... 






20 


33 


28 


House seivants (male) , 






101 


176 


131 


Workers in Silk . , 






63 


71 


58 


Blacksmiths . . « 






48 


51 


63 


Masons and Paviors , 






— 


18 


— 


Porteis and Gardeners , 






478 


410 


351 


Gardeners 






65 


119 


114 


Briekmakers . . , 






— 


— 


49 


Butchers . . , 






53 


52 


52 


Painters and Plumbers , 






33 


45 


50 


Breadmakers . 






35 


69 


52 


Carters . 






73 


87 


82 


Commercial Brokers 






29 


30 


65 


C'erks 






— 


— 


41 


Boatmen . . 






— 


44 


35 


Sawyers . . • 






35 


34 


29 


Pedl irs . 






33 


57 


37 


Wheel wrights • 






10 


— 


18 


Engineers 






2*5 


51 


42 


Coopers . 






20 


32 


23 



We can, however, go further than this and investigate the 
influence of position during work. This question has been 
especially discussed in regard to Inguinal Hernise, and the 
question that has arisen is, " Are various attitudes capable of 
modifying the diameter of the Internal Abdominal Ring and 
of the Inguinal Canal ? " Here again, all that is best known 
on the subject rests upon the authority of Malgaigne, who 
is content to say that occupations requiring the adduction 
and flexion of the thighs expose the bowels to displacement 
much more than the occupations allowing a normal position 
of the body. Thompson and Richet on the other hand, think 
that adduction of the thighs will relax the external ring, it 
being impossible to modify the dimensions of the internal 



HERNLE : KINDS AND FREQUENCY. 47 

ring by special attitudes. If this be really so, the effect of 
position will be to modify not the causation of Hernia but 
only the development when the Hernia has once been formed. 

6. Frequency according to the Side of the Body. — 
Hernias as a rule are more frequent on the right side than 
on the left, and that in the proportion of 7 to 4 or 5. The 
reason for this has been variously expressed. Schinkius thought 
it due to the larger lobe of the liver being upon the right 
side, Martin to the inclination of the mesentery, Cloquet to 
the predominance of those who are right-handed in their 
actions over those who are left-handed. This seems by far 
the best and most plausible way of accounting for the fact, 
since we observe that in all movements of the right side 
the diaphragm forces the abdominal viscera downward, forward, 
and to the right side. Malgaigne as usuai doubts the state- 
ment, and by figures seeks to show that Hernias in right- 
handed persons are more frequently on the left side than on 
the right. Thus of 313 Inguinal Hernias 40 were double, 
and of the 273 remaining, 171 were right and 102 left, while 
of the 273, 1 out of every 11 was left-handed. 

7. Frequency according to Race of Men. — As regards 
the race most frequently afflicted with this abdominal weak- 
ness, it has been found that inhabitants of warm climates 
are more often "ruptured " than those of temperate and cold 
regions. Then of course we can make the general statement 
that the hard toiling nations are more like to be " ruptured " 
than those who lead a more moderate life. This will as well 
apply to the different orders of men in the same nationality, 
and when thus much has been said, we can say no more that 
could be of the least authority or practical value. 



CHAPTER III. 
Anatomy : Descriptive and Surgical. 

anatomy of hernia : descriptive and surgical. 

Of all these varieties, the kinds most commonly met are 
the Umbilical, the two varieties of Inguinal and the Femoral ; 
to these we will now more particularly confine our attention, 
defining minutely the anatomy, coverings and symptoms, their 
several variations under unusual conditions, differentiating diag- 
nostically between them individually, and also between them 
and the other abnormal conditions of the abdominal region 
likely to be confounded with Hernias. For this purpose I have, 
besides consulting other authors, made many extracts from 
Gray, Anderson, Lawrence, Beckitt and Eanney, to whom I 
wish to give due credit for their labours, researches and writings. 1 

SURGICAL ANATOMY OF UMBILICAL HERNIA. 

This protrusion is directly through the abdominal parietes at 
the navel, or umbilicus, or its immediate vicinity. Passing from 
without inwards we meet the integument, superficial fascia, the 
aponeurosis formed by the union of the oblique and transversalis 

1 Descriptive Anatomy. By Henry Gray. — System of Surgical Anatomy. 
By William Anderson. New York, 1822. — A Treatise on Ruptures. By 
W. Lawrence. Philadelphia, 1843. — A System of Surgery. Edited by T. 
Holmes. Vol. IV. — Surgical Diagnosis. By Ambrose L. Ranney. New 
York, 1879. — The Essentials of Anatomy. By William Darling 1 and 
Ambrose L. Rnnney. New York, 1880. 



ANATOMY: DESCRIPTIVE AND SURGICAL. 40 

muscles, the fascia transversalis, a layer of sub-peritoneal cellular 
tissue often containing fat and a pouch of the parietal layer of 
peritoneum, forming the hernial sac. These coverings being of 
more importance in Inguinal Hernia will be there more fully 
described. In Umbilical' Herniae these coverings may become 
so inseparably united and thinned that they appear as one and 
allow the contents of the sac to be seen from the surface. Other 
variations in the coverings have reference to the method of for- 
mation of the sac. If it be suddenly produced, not only may 
the tendon of the external oblique be wanting but also the 
superficial fascia and the fat. If the tumour be formed before 
the separation of the umbilical cord, it passes directly through 
the umbilicus into the substance of the cord and gains from it 
a peculiar covering. No blood-vessels, unless it be superficial 
vessels or abnormal veins, as seen by Manec, Meniere and 
Velpeau, are situated near a Hernia in this region, The 
contents of an Umbilical Hernia are usually both omentum 
and intestine, entero-epiplocele. Other viscera besides the large 
and small intestine may be inclosed by the sac, as for example 
the stomach or uterus. 

The firm margin of the umbilical ring forms an unyield- 
ing ring around the neck of the sac which is itself thicker 
at this point than over the body of the sac. As the tumour 
increases in size it does not extend uniformly over the abdo- 
minal surface but downwards towards the symphysis pubis 
more than in any other direction. It may be sessile with 
an immense base, or pyriform, and suspended by a peduncle 
or stalk. 

In the Fcetus, umbilical Hernia is always in consequence of 
a defective development in the abdominal walls, as I have already 
said, and is often associated with other malformations such as 
hare-lip or club foot. It has a covering formed by the union of 
the peritoneum and the envelope of the umbilical cord. If the 

£ 



50 



HERNIA. 



humour be large, death often takes place from peritonitis a few 
days after birth. 

In the child, umbilical protrusions occur usually after some 
violent muscular exertion, as coughing or crying, are small and 




Fig. 1. — Umbilical Hernia. 

The three most common forms of Hernia, named in the order of their occurrence in the female, 
are Umbilical Femora] and Inguinal. Oblique Inguinal, or Pudendal in the female, is wry 
fine'y shown on the right side of the figure. Umbilical as well as Femoral on the left side 
speak for themse'ves. The fibres and fascia transversalis in the Umbilical region are very 
we'l drawn, and show the appearance of a Hernia in that stage of its formath n when the 
intestine ha^ already passed the internal ring and commenced to protrude from the 
external surface. 



conical and almost always contain only intestine and not 
omentum. 

In the adult I have already said this variety of Hernia is not 



ANATOMY: DESCRIPTIVE AND SURGICAL. 51 

strictly umbilical, but only so-called by convention and for con- 
venience of classification. The tumour is globular or pyriform, 
and in corpulent persons tends to insinuate itself into the adipose 
tissue downwards towards the pubes. Thus it may for years 
exist unsuspected because concealed in this way. In such a 
state too there is great danger of strangulation and fatal results. 
Such Herniae more frequently exist in fleshy women who have 
borne many children, than in men. 

Certain symptoms are characteristic. The tumour at first is 
small, soft and ovoid. It readily reduces by pressure, when a 
distinct sharp outline of the umbilical ring can be felt by the 
finger. On removing the finger the skin either remains creased 
in folds or it gradually distends until the tumour re-appears. On 
coughing a distinct impulse in the tumour is felt by the finger. 
In adults, who have Umbilical Hernia, any tenderness of the 
abdomen, constipation or nausea should be carefully watched as 
giving symptoms of possible strangulation. (For diagnosis from 
Ventral Hernia see Table on p. 80.) 

SURGICAL ANATOMY OF THE ABDOMINAL REGION RELATING TO 

INGUINAL HERNIA. 1 

The superficial fascia of the abdominal region is of two layers, 
between which are the superficial vessels and nerves and the 
inguinal lymphatic glands. It was first described by Camper. 
The superficial layer is thick and areolar, and contains adipose 
tissue. The deep layer is thin, aponeurotic and strong. It 
adheres in the middle line to the linea alba, and below to Pou- 
part's ligament and the fascia lata, although it does not increase 
the strength of the abdominal ring. Between them are the 
superficial epigastric, circumflex iliac and external pudic arteries 
and veins, terminations of the ilio-hypogastric and ilio-inguinal 
nerves and the upper group of the inguinal lymphatics. 

i See p. 160. E 2 



52 HERNIA. 

These cutaneous arteries all arise from the femoral, about 
half an inch below Poupart's ligament. The superficial epigastric 
passes through the saphenous opening, crosses Poupart's liga- 
ment midway between the spine of the ilium and pubes, and 
ascends nearly as high as the umbilicus, anastomosing with the 
deep epigastric from the external iliac and with the internal 
mammary from the subclavian. It supplies the integument and 
fascia. Its vein enters the internal or long saphenous. The 
superficial circumflex iliac runs parallel with Poupart's ligament 
out to the crest of the ilium. The superficial external puclic 
passes inward across the spermatic cord to supply chiefly the 
integument of the penis and scrotum of the male and of the 
labia of the female. 

The ilio-inguinal nerve pierces the transversalis and internal 
oblique muscles, and escaping at the external abdominal ring 
accompanies the spermatic cord to the scrotum and thigh. 

The aponeurosis of the external oblique muscle lies beneath 
the fasciae. It is thin and strong with fibres running down- 
ward and forward. The lower edge of the aponeurosis, thickened 
and stretched like an arch between the anterior superior 
spinous process of the ilium and the spine of the pubes, is 
called Fallopius' or Poupart's Ligament, and under Femoral 
Hernia will be spoken of as the femoral or crural arch. It is 
narrow behind and increases in breadth towards the front. On 
the superior surface is a concavity for the spermatic cord. The 
reflection of this ligament backwards and inwards to the ilio- 
pectineal line is called Gimbernat's ligament, which is about 
an inch in length although larger in the male than in the female 
and almost horizontal in the erect position. It is triangular in 
shape; its outer margin or base, concave and sharp, being in 
contact with the crural sheath and blended with the pubic 
portion of the fascia lata; its apex joining the spine of 
the pubes. A reflection of this ligament extending behind 



PLATE A. 

STUDY OF THE INGUINAL CANAL. 

By BOURGERY. 

[As a curiosity of language, the descriptions of these three plates will be given 
in the words of the original translation.] 

Details of the inferior extremity of the Great Oblique and Transversal, and their 
relations with the Groins and origin of the Thighs. 

Left side of the Subject: Great Oblique, whose aponeurosis is half open, and 
thrown back to shew the interior of the inguinal canal, the cremaster being re- 
moved. The circumference of the ring is preserved in form of a stay. The thigh 
represents the upper extremity of the superficial muscles. 

Right side : Femoral transversal and aponeurosis. 

Explanation of the Plates. 
The explanation refers to two plates which have been combined. 

A, A. Anterior and superior iliac spines. 

B, B. Pubic spines. 

LEFT SIDE. 

1. Inferior extremity of the great oblique. 

2, 2. Its aponeurosis. 

3, 3. Shreds of the aponeurosis, inverted, to show the inguinal canal. 

5. Origin of Poupart's ligament. 

6. Cut of the small bands, from whence the external pillar proceeds. 

7. External pillar, implanted upon the spine of the pubis. 

8. Small band, from whence the internal pillar proceeds. 

9. Internal pillar. Between the two pillars is the inguinal ring. 

10. Internal inguinal ligament. 

11. Extremity of the internal pillar of the right side. 

12. First band of insertion to the pubis, separated from the internal pillar by 
the arcade of passage to the ilio-serotal nerve. 

13. Extremity of the aponem-osis which closes the ring, preserved in form of a 
stay. 

RIGHT SIDE. 

1 4. Origin of Poupart's ligament in the iliac spinal. 

15. Aponeurosis, thrown back upon the thigh. 

16. Its tie, forming the external pillar. • 

17. Aponeurosis of the little oblique, in front of the great right. 

18. Left side: Last ties of this muscle in the gutter of Poupart's ligament. The 
arcade which it forms is raised up by a hook, to let the transversal be seen. 

19. Right side : Extremity of the fibres of the little oblique inverted within, to 
let the aponeurosis of the transversal be seen. 

20. Idem. Transversal. 

21. Idem. Last ties of this muscle in the gutter of Poupart's ligament. 

22. 22. Summit of the arcade which it forms above the internal orifice of the 
inguinal canal. 

23. Aponeurosis of the transversal. 

24. Inferior tie of the pubis. It is the same aponeurosis which is seen through 
the orifice of the left inguinal ring. 

25. 25. Of th-e sides: Thick edge of the fascia-transversalis, which limits tl^e 
superior orifice of the inguinal canal outside, and then unites itself with the gut- 
ter of Poupart's ligament. 

26. 26. Idem. Very fine portion of the same fascia, which forms the internal 
edge of the orifice. Behind a fibro-cellulous sheet are seen the epigastric vessels 
which ascjnd parallelly to the internal edge. 

26, 27. Idem. Ellipsoidal internal orifice of the inguinal canal. 

28. Right side: Superficial aponeurotic leaf, applied upon the crural vessels. 

29. Idem. Section of the internal sapheneous vein, which crosses the femoral 
aponeurosis (inferior crural ring), in order to through itself into the femoral vein. 

30. Left side : Sartor muscle. 

31. Fascia-lata. 34. Anterior right. 

32. Reflected mass of the psoas and iliac. 35. First abductor. 

33. Pectine. 36. Penis. 



ANATOMY : DESCRIPTIVE AND SURGICAL. 53 

the internal pillar of the external abdominal ring to the 
linea alba is called the triangular ligament. In the middle 
line of the body, the fibres of this aponeurosis join with the 
fibres from the aponeurosis of the corresponding muscle on the 
opposite side to form a thickened line from the ensiform cartilage 
to the pubes, the linea alba, formed by the union of the 
aponeurosis of the oblique and transversalis muscles. 

About an inch and a half from the pubes the thickened fibres 
of the aponeurosis separate to form the pillars or columns of the 
external abdominal ring. The internal or superior pillar is 
broad, thin and flat, and attached to the upper edge of the pubes 
near the symphysis. It interlaces with fibres from the opposite 
side. The external or inferior pillar is narrower, thicker and 
stronger, is inserted into the spine of the pubes, and is curved 
around the spermatic cord to form the groove above mentioned. 
The separation of these tendinous pillars leaves a triangular 
opening over the pubes, called the external or abdominal ring. 
The pubes forms the base of the triangle and the tendinous 
columns the sides. At the apex are some curved fibres, inter- 
columnar fibres, which increase the strength of the aponeurosis, 
and are more developed in the male than in the female. Through 
this triangular opening passes the spermatic cord in the male 
and the round ligament of the uterus in the female. Over the 
outer surface of the cord and testis is prolonged a thin fascia, 
the intercolumnar or external spermatic fascia, attached to the 
pillars of the ring. The abdominal ring, or more properly 
triangular aperture, is directed upward and outward. When 
distended by a Hernia it assumes more of a circular form, so 
that then the appellation of ring is much more appropriate. Its 
size and form vary ; sometimes it is rounded, and closely em- 
braces the cord or round ligament, sometimes elongated, and 
sometimes square. It is usually about an inch in it3 long 
diameter from pubes to internal angle, and about one half inch 



54 



HERNIA. 



transversely between the columns. It is larger and stronger in 
the male than in the female. 

The fascia of the obliquus interims muscle along the middle 
line over the rectus for the upper two-thirds of its extent is 
divided into t\AO layers, of which the outer is blended with the 
fascia of the obliquus externus, while the inner is blended with 
the transversalis fascia. In the lower third all this expansion of 




Fig. 2. — Inguinal Hernia. 

This figure shews the various coverings ; 1, shin, superficial fascia; 3. intercolunmar fascia; 4, 
crtmaster muscles, infundibu ifunri fascia, subbeiuus ee.lular tissue; 2. sac, epigastric 
artery with veins on either side of it. 



fasciae passes in front of the rectus. The fibres of the internal 
oblique from the upper half of Poupart's ligament arch down- 
ward and inward across the spermatic cord, to be inserted with 
the tendons from the transversalis as the conjoined tendon into 
the crest of the pubes and pectineal line for half an inch. It 
lies behind, and so closes Gimbernat's ligament, and the ex- 
ternal abdominal ring, and strengthens the ring towards the 
abdomen. Sometimes it is insufficient to resist the pressure 



ANATOMY : DESCRIPTIVE AND SURGICAL. 55 

from within, and is protruded as one of the coverings of direct 
inguinal Hernia. 

The Fascia Transversalis lies between the inner surface of 
the transversalis muscle and the peritoneum, and closes the 
ring of the external oblique toward the muscle ; otherwise there 
would be a direct opening into the abdomen behind the ring. 
Thick and dense in the inguinal region, it becomes thin and 
cellular as it ascends toward the diaphragm. 

The internal abdominal ring is an oval opening, running 
upwards and downwards, much larger in the male than in the 
female, situated in the transversalis fascia "midway between 
the anterior superior spine of the ilium . and the spine of the 
pubes, and about half an inch above Poupart's ligament." The 
following description of this ring is taken from Sir Astley 
Cooper, who first noticed the fascia in which it occurs. 

The edges of this ring " are indistinct on account of its cellular 
connections with the cord ; when these are separated, the fascia 
of which it is formed will be found to consist of two portions : 
the outer strong layer, connected to Poupart's ligament, winds in 
a semi-lunar form around the outer side of the cord and bounds 
the aperture by a distinct margin, from which a thin process may 
be traced passing down upon the cord. The inner portion 
which is found behind the cord is attached to, but less strongly 
connected with, the inner half of the crural arch, and may be 
readily separated from it by passing the handle of a knife 
between it and the arch. It ascends between the tendon of the 
transversalis, with which it is immediately blended, passes 
around the inner side of the cord, and joins with the outer 
portion of the fascia above the cord, being at length firmlv 
fixed in the pubes ; the inner margin of the ring is less defined 
than the outer, the fascia transversalis being doubled inwards 
towards the peritoneum to which it is firmly attached. Thus, 
then, it appears that the internal ring is not a circumscribed 



56 HERNIA. 

aperture like the external abdominal ring, but is formed by 
the separation of two portions of fascia, which have different 
attachments and distributions at the crural arch ; the outer 
portion terminating in Poupart's ligament while the inner 
portion will be found to descend behind it, to form the anterior 
part of the sheath that envelopes the femoral vessels. The 
strength of this fascia varies in different subjects ; but in all 
cases of inguinal Hernia it acquires considerable strength and 
thickness especially at its inner edge ; and if these parts had 
been formed without such a provision, the bowels would, in 
the erect posture, be always capable of passing under the edge 
of the transversalis muscle, and no person would be free from 
inguinal Hernia. 1 " 

The opening then in the abdominal parietes for the passage 
of the spermatic cord is not a simple aperture, but an oblique 
canal, the abdominal or Inguinal Canal, although it is not 
properly a canal unless distended by a Hernia. In its normal 
state it is merely a flattened passage. The crural arch running 
from the anterior superior spine of the ilium to the spine of the 
pubes, and forming a channel in which lie the psoas and iliacus 
muscles, with the femoral vessels, gives attachment to the internal 
oblique and transversalis muscles, and contains in its lower half 
the spermatic cord or the round ligament. The external oblique 
presents in the lower and inner parts of its aponeurosis above 
the pubes the triangular opening called the external ring, but 
now more properly the lower or external opening of the inguinal 
canal. This space between the tendinous columns of the ring 
is closed behind by the insertion of the internal oblique into 
the pubes. Hesselbach has accordingly called it the " crural 
surface of the anterior inguinal ring." It is the only place where 
the internal is left uncovered by the external oblique muscle. 
The corresponding surface on the posterior or abdominal side 
1 Cooper on Hernia, part I. p. G, ed. 2. 



ANATOMY: DESCRIPTIVE AND SURGICAL. 57 

of the canal is a triangular space bounded on the inner side by 
the outer edge of the rectus abdominis, on the lower by the 
pubes, or as usually given by, Poupart's ligament, and on the 
outer by the femoral and epigastric vessels. This has been 
called the "triangular inguinal surface," or Hesselbach's Triangle. 
It is the weakest part of the abdominal parietes, being covered 
only by the transversalis fascia and the conjoined tendon. The 
inguinal canal is bounded posteriorly, or on the abdominal 
aspect, by the transversalis fascia, in which is the opening of 
the internal abdominal ring, higher and more external than 
the external ring, and about an inch and a half distant from it. 

Besides the superficial epigastric artery coming off from the 
femoral, the surgeon must pay particular attention to the deep 
epigastric from the external iliac. It arises immediately above 
the crural arch in a loose cellular structure. Concealed at first 
by the crural arch, it lies behind the obliquus internus and 
transversalis, and is covered by the spermatic cord just before 
the cord enters the inguinal canal. It ascends obliquely inward 
between the transversalis fascia and peritoneum to the outer 
margin and posterior surface of the rectus, running "along 
the lower and inner edge of the internal abdominal ring, in 
general, precisely along the inner margins, but sometimes rather 
nearer to the pubes, passing at the distance of nearly an inch 
from the upper extremity of the ring of the external oblique." 
It lies behind the inguinal canal and immediately above the 
femoral ring. 

It is accompanied by two veins, the larger of which is always 
found upon the inner side. They unite into a single vein before 
they terminate in the external iliac vein. Several small branches 
of the artery ought to be known to the operating surgeon, the 
cremasteric, which accompanies the spermatic cord, the pubic, 
which runs across Poupart's ligament and then descends to 
the inner side of the femoral ring and the muscular branches. 



58 



HERNIA. 




Fig. 3. 

Superficial dissection of inguinal and crural regions. Below the groove up. - )!! 
front of thigh is seen the triangular depression forming the lower part ot 
groin. This is described in connection with Femoral Hernia. Above the 
pubis may be felt the opening, in the deep parts, of the superficial abdominal 
ring through which the spermatic cord escapes to testicle. Beneath the 
skin of groin and fascia superficialis are two layers, between which are 
found the superficial vessels and lymphatics. The layer below this is 
made up of elastic areolar tissue and fat, closely attached to Poupart's liga- 
ment at spine of pubis and cr^st of ilium, g. Crossing the groin are seen 
three blood-vessels turned obliquely inwards and upwards from common 
femoral artery. Outer one, superficial circumflex iliac, passes up to superior 
iliac spine, d. The middle one, superficial epigastric, supplying glands and 
integuments of groin to umbilicus, e. Inner one, /, superficial external 
pubic, enters fascia lata near the pubis, crossing beneath spermatic cord to 
scrotum and root of penis. The external pubic is liable to be divided in 
cure of Inguinal Hernia ; if a dull bistoury be used in making the division, 
haemorrhage is less liable to occur, unless the vessel is very much enlarged, 
which is the case sometimes in old and large ruptures. 

The abdominal wall is made up of layers of muscular and aponeurotic tissue 
below the iliac crests. The external oblique is very strong, and the iibivs 
curve downwards and inwards towards median line and pubis, forming with 
other tendons a vertical line and by union with opposite side linea alba. 



ANATOMY : DESCRIPTIVE AND SURGICAL. 59 

Externally towards thigh, iibres growing thicker and oblique, running in 
with fascia lata, and uniting with deeper fascia form crural arch or ligament 
of Ponpart, </. This band of fibres is attached to, and forms an arch between 
anterior superior iliac spine and spine of pubis. It has a slight convexity 
downward, outward, and backward so as to form the hollow of the groin. 
The fibres of the aponeurosis are bound together by tough areolar tissue 
which can be traced downward into the inter columnar fascia, h. Through 
various sized openings in this fascia pass vessels and nerves into abdominal 
wall. One of these larger openings is the external ring, i. 

There are considerable variations in the point of origin of the 
artery. It may arise " from any part of the external iliac 
between Poupart's liagment and two inches and a half above it, 
or it may arise below this liagment .from the femoral or from 
the deep femoral." 

The measurements of these parts vary so in the two sexes 
that the subjoined tables by Sir Astley Cooper, from the measure- 
ments of well-developed persons, will be of especial value. 
Although the distances will be somewhat different according 
as the person be large or small, the relative proportions will 
be the same. 

From symphysis pubis to anterior superior spine of ilium . 5| 

to tuberosity of pubes 

to inner margin of the lower open- 
ing of the abdominal canal 

to inner edge of the upper opening 

to middle of iliac artery 

to iliac vein 

to origin of epigastric artery . 

to course of epigastric artery on 
inner side of upper opening 

to middle of the lunated edge of 

fascia lata . 2f 3y 

From the anterior edge of the crural arch to the saphena 

major vein .... 1 1} 

From symphysis pubis to noddle of crural ring . 2£ 2| 

The transversalis muscle and fascia with the epigastric 
vessels which form the anterior boundary of the abdomen are 
lined behind by the peritoneum, which presents a well-marked 
depression or pouch. A thin fibrous prolongation extends for 



Male. 


Female. 


inches. 


inches. 


61 


6 


n 


If 


i 


1 


3 


H 


H 


3§ 


2| 


n 


3 


H 


2| 


2| 



60 



HERNIA. 




Fio. 4.— Rule. 

This sliding and revolving rule will be found very handy in taking these anatomical measure- 
ments. This was loaned to me by T. Bryant, 'Surgeon at Guy's Hospital. 



ANATOMY: DESCRIPTIVE AND SURGICAL. 61 

a short distance over the front of the spermatic cord, and is the 
remains of the pouch of peritoneum which in the foetus accom- 
panies the descent of the cord and testis into the scrotum, and 
which soon after birth begins to be obliterated. (See page 13). 
The spermatic vessels situated behind the peritoneum 
descend over the psoas and iliacus internus muscles connected 
to them by loose cellular tissue, and at the divisions of the 
transversalis fascia are joined by the vas deferens at an acute 
angle. This union forms the spermatic cord, composed there- 
fore of arteries, veins, lymphatics, nerves, and vas deferens 
invested by its proper coverings. Making a sudden bend up- 
ward, it enters the inguinal canal through the inner abdominal 
ring, and running obliquely downward and inward in the in- 
guinal canal between the transversalis fascia and .the aponeurosis 
of the external oblique, emerges at the external abdominal ring. 
It then descends nearly vertically into the scrotum, lying on 
the outer pillar of the external ring so as to cover its insertion 
into the pubes. 

In its passage through the inguinal canal the cord is 
strengthened by the cremaster muscle, which consists of scattered 
bundles of pale reddish fibres derived from the internal oblique 
during the descent of the testis. They form around the cord 
and testis a series of inverted arches or loops, rather difficult 
to dissect. As to their insertion, M. Cloquet says, " the lower 
fibres of the internal oblique, traversing the external angle of 
the ring in front of the cord, ascend again immediately, to be 
fixed to the pubes behind the external pillar of the ring, forming 
loops of small extent, with their concavity directed upward." 

These parts forming the cord are joined together by a cellular 
structure which Scarpa thus describes : — 

"The soft cellular texture which envelopes the spermatic 
vessels behind the great bag of the peritoneum, and accom- 
panies them under the fleshy edge of the trans versus muscle 



62 



HERNIA. 



passing with them through the separation of the lower fibres of 
the obliquus internus and along the inguinal canal into the 
groin and scrotum, continues to surround them as far as the part 
where they terminate in the testicle. This cellular investment, 




Fio. 5. 

Deep dissection of inguinal canal and abdominal wall, a, external oblique thrown 
back over Poupart's ligament ; b, internal oblique ; c, transversalis muscle ; 
d, conjoined tendon ; e, rectus muscle ; /, transversalis fascia ; g, triangular 
aponeurosis formed by a layer of fibrous tissue passing across linea alba from 
aponeurosis of external oblique of opposite side. These fibres pass outward 
and downward to pubic symphysis, crest and spine, or even to pectineal line, 
where they are implanted with those of the conjoined tendon ; h, muscular 
fibres of the cremaster. 

The fascia transversalis, uniting at the groin with fibres of the tendon of the 
transversalis muscle, is closely connected with Poupart's ligament, iliac fascia 
and conjoined tendon. Here it forms the oval opening of the internal ab- 
dominal ring and gives off over the cord, the funnel-shaped investment 
called the fascia propria or infundibularis, i. 



ANATOMY: DESCRIPTIVE AND SURGICAL. 63 

being a continuation of that which connects the great bag of 
the peritoneum to the muscular and aponeurotic parietes of the 
abdomen, becomes thicker and more copious as it approaches the 
part where the vessels pass out of the inguinal ring, and after 
that passage it is enclosed together with the vessels and the 
tunica vaginalis testis in the muscular and aponeurotic sheath 
formed by the cremaster, which extends to the bottom of the 
scrotum. If we make a small opening into the upper part of 
the sheath and impel air through it, the cellular texture is im- 
mediately distended, and the cord is swelled into the form of a 
cylinder extending from the groin into the scrotum as far as the 
attachment of the vessels to the testicle, where a circular groove 
or depression is seen marking the boundary between the cellular 
substance of the cord and the tunica vaginalis testis. While 
the part is thus artificially distended we may carefully slit up 
the sheath of the cremaster and expose the investment of the 
cord, which is then seen as a vesicular spongy tissue with large 
and long cells capable of extension without tearing. The 
spermatic vessels are seen running through it separate from 
each other, and near them is that prolongation of the peritoneum 
which constitutes in the infant the neck of the tunica vaginalis 
testis. The diffused hydrocele of the spermatic cord affords 
another proof how easily this cellular texture may become dis- 
tended. The cellular sheath of the spermatic cord, which con- 
stitutes an investment of tolerably close texture, is connected to 
the margins of the opening of the trans versalis, and again to 
the external abdominal ring. The cremaster muscle contributes 
further to fix and support the cord in its passage through the 
abdominal parietes, while it provides for the necessary move- 
ments of the testicle." 

To recapitulate : of inguinal Hernia the great majority of 
cases are of the external or oblique variety. The viscera pro- 
trude "through the opening left between the two portions of the 



64 



HERNIA. 



fascia transversalis and under the margin of the internal oblique 
and transversalis muscles : that is, at the point where the 
tunica vaginalis communicates with the abdomen in the foetus, 
and where the spermatic cord passes out in the adult." The 
mouth of the sac is at the upper or inner opening of the 




Fig. 6. 

Dissection from the peritoneal surface of the parts affected by an oblique rupture ; 
peritoneum, its fascia and the transversalis fascia are removed. The sac is cut 
off at its neck in the deep ring. The epigastric artery is seen below the neck, 
but has been removed at the inner side to show conjoined tendon, h. 



inguinal canal, and is therefore midway between the anterior 
superior spine of the ilium and the spine of the pubes. The 
normal distance between the internal and external rings is 
rarely seen in Hernia? of long standing ; in fact the normal 
distance is rarely preserved in any complete inguinal Hernia. 
The spermatic cord is placed behind the hernial sac. After the 



ANATOMY : DESCRIPTIVE AND SUKGICAL. 



65 



Hernia has escaped beyond the external ring, however, many 
variations in the relations of the cord to the sac may be pre- 
sented. It may be found at the sides or even on the anterior 
surface, or, as often happens, the vas deferens and the spermatic 
vessels, owing to the great pressure following the distension, may 




Fig. 7. 

Dissection of Inguinal and Crural Hernia from internal surface, the peritoneum 
and fascia being removed, a, external iliac artery ; b, epigastric artery, 
•branch of a ; d, deep circumflex iliac, lying in Hesselbach's triangle ; e, rec- 
tus muscle ; /, fascia transversal is ; g, vas deferens or spermatic duct ; 
h, spermatic plexus of veins with artery and nerves ; i, obliterated cord of 
hypogastric artery ; k, lymphatic glands. At the internal ring may be seen 
subperitoneal fascia, I, enveloping the cord, h. 

separate, the former on the inner side of the tumour and the 
latter on the outer. An internal or direct inguinal Hernia pro- 
trudes through the fascia transversalis at Hesselbach's triangle 
and then through the external abdominal ring. Such a Hernia 

F 



66 HERNIA. 

according to Cooper, takes place " if this tendon is unnaturally 
weak ; or if from malformation it does not exist at all ; or from 
violence has been broken." The spermatic cord lies usually on 
the outer side of the sac, although it may lie behind it as in the 
external or oblique variety. The epigastric artery is pretty 
constant in its relation to the Hernia, that is, in its normal 
state about three-quarters of an inch from the upper and outer 
extremity of the external ring, although Hesselbach records a 
case in which he found the epigastric so near the symphysis 
pubis that had a direct Hernia taken place the artery would have 
been upon the inside of the mouth of the sac. 

The inguinal canal has the following boundaries, which have 
been taken from Darling : — 

fSkin. 

In front (5 structures^ i Su P erficial fascia ( 2 layers). 
in tront p structuiesK External oblique ( entire i eri o-th). 

^Internal oblique (outer third). 

Conjoined tendon of internal oblique 

and transversalis. 

i Transversalis fascia. 
Behind (5 structures) Triangular ligament 

Sub-peritoneal tissue and fat. 
I Peritoneum. 

Above (2 structures) ( fibres of internal oblique. 
x ' ^Jbibres of transversalis. 



Below (2 structures) ( Poupart's ligi 
v ' \ Transversalis 



ament. 
fascia. 



Femoral Hernia. 1 — The superficial fascia of the femoral 
region is of two layers just as in the abdominal region, between 
which are the cutaneous vessels and nerves and the lymphatic 
glands. These vessels are the internal saphenous vein and 
the superficial epigastric, superficial circumflex iliac, and super- 
flcial external pubic arteries from the femoral, while the 
cutaneous nerves are from the ilio-inguinal, genito-crural, and 
anterior crural from the lumbar plexus. The ilio-inguinal 

1 See p. 162. 



ANATOMY: DESCRIPTIVE AND SURGICAL. 



C7 



nerve lies upon the inner side of the internal saphenous vein, 
the genito-crural on the outer side, and the middle and external 
cutaneous nerves still more external. The superficial layer 
of this superficial fascia is continuous above with the super- 
ficial fascia of the abdomen, while the deeper layer is con- 
tinuous below with the fascia lata a little below Poupart's 
ligament. Where it adheres to the saphenous opening in 
this fascia lata, it is pierced by small blood-vessels and 
lymphatics ; hence the name cribriform fascia has been applied 
to it in this situation. 




Fro. 8.— Femoral Hernia. 



The deep fascia lying beneath the superficial fascia is called 
from its great extent the fascia lata. At the upper and inner 
side of the thigh, a little below Poupart's ligament and on 
the pubic side of its centre, is seen an oval opening directed 
obliquely downward and outward about an inch and a half 
in length and half an inch in width. This is the saphenous 
opening. To understand it properly the fascia lata may be 
described as consisting of two portions, iliac and pubic. The 
former "is attached externally to the crest of the ilium and 
its anterior superior spine, to the whole length of Poupart's 

F 2 



68 HERNIA. 

ligament as far internally as the spine of the pubes, and to 
the pectineal line in conjunction with Gimbernat's ligament, 
where it becomes continuous with the pubic portion. From 
the spine of the pubes it is reflected downwards and out- 
wards, forming an arched margin, the outer boundary (superior 
cornu) of the saphenous opening. This is sometimes called 
the falciform process of the fascia lata or femoral ligament of 
Hey ; it overlaps and is adherent to the sheath of the femoral 
vessels beneath ; to its edge is attached the cribriform fascia, 
and it is continuous below with the pubic portion of the fascia 
lata by a well-defined curved margin." 1 The jcmoic portion 
attached above to the pectineal line and internally to the 
margin of the pubic arch is upon the inner side of the 
saphenous opening, and at its lower margin is continuous 
with the iliac portion. We see therefore that the iliac portion 
"passes in front of the femoral vessels, the pubic portion 
behind them, while an apparent aperture exists between the. 
two through which the internal saphenous joins the femoral 



vein. 



2 



The outer margin of the saphenous opening forms a curved 
process, the falciform process of Burns, Burns' or Hey's liga- 
ment or femoral ligament. It curves inward upon its upper 
border to join Poupart's ligament, the spine of the pubes and 
pectineal line where it is continuous with the pubic portion. 
The inner margin of the opening is on a lower plane, lying 
behind the femoral vessels, and is less distinctly marked in its 
contour. When the limb is extended or rotated outward, the 
saphenous opening will be found tense and constricted; on 
the other hand, when the limb is flexed, or rotated inward, the 
opening is relaxed. So that this position of the limb is an 
important point to be borne in mind during the operation 
of taxis. (See page 214) 

1 Gray. 3 Ibid. 



ANATOMY: DESCRIPTIVE AND SUEGICAL. 69 

The triangle at the upper and anterior surface of the thigh 
where femoral Hernia makes its appearance is called Scarpa's. 
It is bounded above by Poupart's ligament, which forms the 
crural arch already described under inguinal Hernia, and which 
has a reflection at the pectineal line called Gimbernat's liga- 
ment. Externally this triangle is bounded by the sartorius and 
internally by the adductor longus, while its apex is formed 
bv the meeting of these muscles. 

Covered by the iliac portion of the fascia lata, and resting 
upon the pubic portion of the same fascia, is a continuation 
downward of the abdominal fascia, called the femoral sheath, 
the transversalis fascia passing m front of the femoral vessels 
and the iliac behind them. About an inch below the saphenous 
opening, the femoral sheath intimately blends with the vessels, 
but at Poupart's ligament it is much larger; hence it presents 
a funnel shape. 

Besides the crural arch already described, we have the deep 
crural arch, which is a thickened band of fibres running across 
and in front of the crural or femoral sheath. " It is apparently 
a thickening of the fascia transversalis, joining externally to 
the centre of Poupart's ligament and arching across the front 
of the crural sheath, to be inserted by a broad attachment into 
the pectineal line behind the conjoined tendon." It is often 
altogether wanting. 

P>y removing the anterior wall of the femoral sheath we 
see the femoral artery and vein separated by a thin septum ; 
the artery being upon the outer side and the vein upon the 
inner. The interval between the vein and the inner wall of 
the sheath is filled only by loose areolar tissue and a few 
lymphatics ; it is the femoral or crural canal through which 
femoral Hernia protrudes. It should be borne in mind by the 
dissector that this canal only exists as a distinct canal when 
distended by a Hernia or other tumour, or when artificially 



70 HERNIA. 

separated in dissection. It varies in length from a quarter 
to a half an inch, and extends from Gimbernat's ligament to the 
saphenous opening. It is bounded in front by the transversalis 
fascia, Poupart's ligament, and the falciform process of the 
fascia lata, behind by the iliac fascia and the pubic portion 
of the fascia lata, on the outer side by the fibrous septum 
between the artery and vein, and on the inner side by the 
junction of the transversalis and iliac fascia, which cover the 
outer edge of Gimbernat's ligament. The lower opening of 
this femoral canal is the saphenous opening closed by the 
cribriform fascia, already fully described, while the upper 
opening is the femoral or crural ring, closed by the septum 
crurale. This septum crurale is a layer of condensed areolar 
tissue with its upper surface concave and separated from the 
sub-areolar tissue and peritoneum by a lymphatic gland. When 
this sub-areolar tissue has become infiltrated with a large 
amount of adipose tissue it may frequently be mistaken for 
the omentum, and lead one astray in his diagnosis. As the size 
and degree of tension of the saphenous opening is modified 
by the limb being flexed and rotated inward, so is the 
size and tension of the femoral canal likewise favourably 
influenced. 

The femoral ring, like the canal, is an " artificial product " 
made by the descent of a femoral Hernia. It leads into 
the cavity of tl e abdomen, is of an oval form, measures 
about half-an-inch in its long, or transverse diameter, and 
is larger in the female than in the male; hence the more 
frequent occurrence of femoral Hernia in the former sex than 
in the latter. 

In front it is bounded by Poupart's ligament and the deep 
crural arch, behind by the pubes, internally by Gimbernat's 
ligament, the conjoined tendon, the transversalis fascia, and 
the deep crural arch, externally by the femoral vein. 



ANATOMY : DESCRIPTIVE AND SURGICAL. 71 

It is important to bear in mind that the spermatic cord and 
round ligament lie immediately above the anterior margin of 
the femoral ring, that the femoral vein lies upon the outer 
side of the ring, that the epigastric artery crosses the upper 
and outer angle of the ring, and that the obturator artery, 
instead of lying in its ordinary position on the outer side of 
the ring, occasionally " curves along the free margin of Gim- 
bernat's ligament," and therefore runs along nearly the whole 
circumference of the ring. 

The viscera in a femoral Hernia descend from the abdomen 
at first in nearly a perpendicular direction and lie in the 
hollow of the pectineus muscle. Covering the peritoneal sac 
is an investment named by Sir Astley Cooper the fascia 
propria. It lies "immediately external to the peritoneal sac 
but is frequently separated from it by more or less adipose 
tissue," and anatomically it is identical with the sub-serous 
cellular tissue already mentioned. 

The protrusions of the hernial sac occur almost invariably on 
the inner side of the femoral vein. Cloquet, however, says, 
" The epigastric artery may be found on the inner side of the 
sac of a crural Hernia, the parts having descended in front of the 
femoral vessels ; " and, together with Hesselbach, thinks this 
sufficient to warrant the division of femoral Hernia into inter- 
nal and external. Besides these varieties, Cloquet also mentions 
a case where the Hernia •' passed through an opening in the pos- 
terior part of the sheath, so that it lay immediately upon the 
pectineus and behind the femoral artery and vein." Such cases 
are however very rare ; by far the greater number being of the 
internal variety. 

To recapitulate. The femoral ring is situated internal to the 
femoral vessels, and is bounded as follows : — 

Above (2 " structures) ( Poupnrt's ligament 
* ' \ Deep crural arch. 



72 HERNIA. 

( Pubic bone. 

t> i^ n i 1 \ 1 Pectineus muscle. 

Below (4 structures) < 1V * 

v ' l Iliac iascia. 

( Pubic portion of fascia lata. 

f Gimbernat's ligament. 

T . ii /i A *. v I Conjoined tendon. 
Internally (4 structures) 1 ^ .^ ^ ^ 

\Transversalis fascia. 
Externally (2 structures) Femoral vein and septum. 

Going from the spine of the pubes outward, we meet the 
following in their order : — 

1. Gimbernat's ligament 4. Femoral artery. 

2. Femoral opening. 5. Anterior crural nerve. 

3. Femoral vein. 

The femoral canal, about half an inch long, extends from the 
femoral ring, where it is closed by the septum crurale, to the 
upper part of the saphenous opening, closed by the cribriform, 
fascia, and is bounded as follows : — 

{Poupart's ligament. 
Fascia transversalis. 
Falciform process of fascia lata. 

Behind (2 structures) { ^e^ortion of fascia lata. 

Eternally (2 structures) {talcum. 

/"Fascia transversalis. 

Internally (4 structures)-! SK**^' r 

* v . ' I Gimbernat's ligament. 

VjJeep crural arch. 

Let us now look at the formations of a hernial sac. 

The essential parts of a hernial tumour are three in number — 

The sac. 

The tissues enveloping the sac. 

The contained viscus. 



ANATOMY : DESCRIPTIVE AND SURGICAL. 73 

The sac is a prolongation of the peritoneum, and consists of 
the mouth, which is continuous with the abdomen ; the neck, 
that portion of the parietes through which the sac protrudes ; 
the lody, which makes up the main bulk of the tumour, and 
the fundus, which is that portion of the body furthest from the 
abdomen. The neck undergoes many abnormal changes. It 
becomes thickened, discoloured, and opaque, from deposition of 
plastic adhesions, from irritation by a truss, or from a puckering 
of the sac consequent upon compression within the aperture 
from which it protrudes. 9 It may, instead of being single, con- 
sist also of two constrictions representing the anatomical condi- 
tion of the surrounding parts, while Gant mentions a large 
scrotal Hernia with three such necks. 1 

The lody varies greatly in different individuals, both in size 
and shape, being usually pyriform, but often globular, ovoidal, 
cylindrical, or constricted, like an hour-glass. It varies in size 
from a cherry to a tumour as large as a man's head. At first it 
is thin, but often, as in femoral, it becomes thickened and lami- 
nated in structure, although in umbilical Hernia? it is like to 
be thinned and atrophied, while in some rare cases there may 
be a fibrous or even calcareous degeneration of the component 
tissues. 10 

The formation of the sac varies in different Hernise. The 
congenital hernial sac is found only in Inguinal Hernise, and is 
a tubular prolongation of the peritoneum formed by the descent 
of the testicle, the natural fcetal opening of the tunica vaginalis 
not having been closed because of some abnormal condition. 
The formation of such a Hernia is rapid, occurs in infancy, and 
has only a single layer of peritoneal covering. The artificial 

1 The aperture may become altered too in shape, losing its triangular 
form, and becoming circular, and gradually with the lapse of time being 
displaced toward the middle line by the elongation of the peritoneum and 
the thickening of the transversalis fascia, so that the two rings become 
merged into one. 



74 HERNIA. 

sac formed by the protrusion of a viscns through the abdomen 
by the stretching of the parietes, has been named by Birkett 
the "acquired sac." The formation of such a Hernia is gradual, 
and belongs only to middle and old age. 1 

In some cases, a3 in internal and csecal Hernias, in cystocele, 
or in rupture of the sac, either from violence or ulceration, the 
sac may be absent. On the other hand, just as there may be 
two or more necks to a single sac, so there may be two sacs 
protruding through the same aperture, and forming a double 
Hernia. Indeed, Sir Astley Cooper mentions a case where six 
sacs occurred together in the same person. 

Proceeding from without inward, and observing the coverings 
of a Hernia, we meet in Inguinal Hernise the following tissues : — 

Oblique. Direct. 

1. Integument. 1. Integument. 

2. Superficial fascia, 2 layers. 2. Superficial fascia, 2 layers. 

3. Interco!umnar fascia. 3. Intercolumnar fascia. 

4. Cremaster. 4. Conjoined tendon (occasionally). 

5. Fascia transversalis. 5. Fascia transversalis. 

6. Sub-serous cellular tissue. 6. Sub-serous cellular tissue. 

7. Peritonsum. 7. Peritoneum. 

In femoral hernia the following are the coverings : — 

1. Integument. 

2. Superficial fascia. 

3. Cribriform fascia. 

4. Femoral sheath, or fascia profunda. 

5. Septum crurale, or sub-serous cellular tissue. 

6. Peritoneum. 

Since the superficial fascia consists of two distinct layers, the 
coverings of Inguinal Hernia are generally considered to be eight, 
and those of femoral seven, in number. 

The coverings of the hernial sac may undergo pathological 
modifications. The peritoneum is very tough and firm in 
texture, being able, according to Scarpa, to uphold a weight of 
fifteen pounds. It usually suffers little change, although it 

1 See p. 16. 



ANATOMY: DESCRIPTIVE AND SURGICAL. 75 

may become thickened, opaque, and firmer near the abdominal 
opening, and may have serous or lymph effusions upon it. 11 The 
sub-serous cellular tissue often becomes thickened, exceedingly 
vascular, and fatty, so as greatly to resemble omentum, while 
the fasciae and integument become stretched and, if a truss has 
been long worn, very much thickened and condensed. The 
fibrous and sub-cellular tissues covering old and long standing 
hernise often become so blended together that it is impossible 
not only for the young student, but also for the skilled and 
practised dissector, to distinguish more than a single layer. 12 

The muscular fibres are, however, usually more distinct in 
their structure, and preserve their identity intact. 




Fzo. 9.— Coverings of Femoral Hernia. 1, skin ; 2, superficial fascia, cribriform fascia ; 
3, crurale sheath ; 4, femoral sheath ; 6, septum crurale ; 6, peritoneum. 

Adhesions are commonly within the sac, and in long-standing 
cases, although often a hernia is rendered irreducible on account 
of fibrous adhesions to the tissues surrounding the rings. When 
the adhesions are within the sac, they may be between the 
coils of viscera, between them and the omentum, or between 
the contents and the walls of the sac. In recent cases these 
adhesions are soft and easily broken down, but in old cases 
they often become very firm and fibrous, and especially strong 
around the neck of the sac. 

The symptoms of a reducible Hernia are as follows : — 
There is a soft compressible swelling or tumour in the 



76 HERNIA. 

abdominal parietes, or on tlie thigh, commonly in the groin, either 
above (inguinal) or below Poupart's ligament (femoral). This 
tumour enlarges, and is well marked when the patient stands, 
and still more so when he coughs or forces down. Coughing 
will moreover cause a distinct pulsation perceptible to the 
touch. When the patient assumes the recumbent position the 
tumour diminishes, and can be reduced by proper manipulation 
in the direction of its protrusion. The tumour is like to be 
larger after a meal, and the patient to suffer from flatulence, 
grumblings in intestines, and other inconveniences resulting 
from the difficulty of passage of matter through the protruded 
intestines. There is usually no other pain or sign of inflamma- 
tion. The hernial tumour, if it attains any considerable size, 
becomes pendulous, hanging in scrotal and umbilical hernise 
even to the knees. Such hernise may at any time be made 
irreducible by blows or pressure, by improper manipulation, by 
the application of a truss when the hernia has not been fully 
reduced, or by undue violence in taxis. Oftentimes, although 
the intestine can be readily restored to its normal position, the 
sac remains protruding because of adhesions which have formed. 
Further manipulation is then of no avail, and may produce a 
severe inflammation. Although it has been sometimes recom- 
mended to confine these tissues in the aperture of the rings in 
order to excite adhesive inflammation for the support of the 
Hernia, such methods have usually been fruitless in results 
except in young children. 

The presence of fluid in the hernial sac will be almost certain 
to obscure the visceral nature of the contents of an epiplocele 
or of an entero-epiplocele so as to simulate an enterocele. 
Hydrocele of the cord may also lead us far astray in our 
diagnosis of a Hernia as the following case will show. 

A little boy with a congenital oblique inguinal suffered at the 
age of five a strangulation. Dr. J. Leonard, an old friend of 



PLATE B. 

ANTEEIOE PAEIETES OF THE TRUNK. 

By BOURGERY. 

Dciails of the Inferior Part of the Great and Small Oblique Muscles, and of their 
relations with the Groins and the Origin of the Thighs. 

Right side of Subject : Great oblique and femoral aponeurosis. 

Left side; Small oblique, and superior part of the muscles of the thigh. 

Explanation of the Plate. 

A, A. Anterior and superior ridges of the bones of the iles. 

RIGHT SIDE. 

B. Ridge of the pubis. 

1. Interior muscular fibres of the great oblique. 

2. 2, 2. Aponeurosis of the same muscle. 

3. 3. Section of the aponeurosis upon the white line. 

4. 4. Ligamentous small bands for strengthening, which form at their extrem- 
ity the pillars of the inguinal ring. 

5. 5. Fold of the aponeurosis, or Poupart's ligament. 

6. External pillar of the inguinal canal. * 

7. Its internal pillar intercrossed upon the pubis with that of the opposite side. 
More within there is a vascular aponeurotic slit. 

8. Opening of the inguinal ring. 

9. 9. Oblique fibres arising from Poupart's ligament, which, crossing the direc- 
tion of the aponeurosis, close above the. opening of the ring, and, together, bind 
its two pillars. 

10. Superficial leaf of the fascia-lata aponeurosis, in front of the crural canal. 

11. Falciform fold of the aponeurosis, forming the free edge of the inferior ori- 
fice of the same canal. 

12. Section of the sapheneous vein which passes through this orifice. 

LEFT SIDE. 

From 13 to 13. Inferior muscular fibres of the internal oblique muscle. 

14. Arcade, formed above the cord of the spermatic vessels by the last fibres, 
of which some detach themselves in order to concur to the formation of the cre- 
master muscle. 

15. Aponeurosis of the small oblique muscle. 
16, 16. Gutter of Poupart's ligament. 

17. 17. Aponeurosis of the great oblique inverted. 

18. External pillar. 

19. Superior tie of Poupart's ligament, or internal inguinal ligament. 

20. Internal pillar. Between the two pillars, the opening of the inguinal ring, 
crossed by the spermatic vessels, is seen. Above the internal pillar is the apo- 
neurotic slit indicated on the other side. 

21. Sartor muscle. 

22. Fascia lata. 

23. Anterior right of the thigh. 

24. Bundle of the psoas and iliac. 

25. Pectineus. 

26. First abductor. 
; 27. Penis. 

28. Cord of the spermatic vessels. 

29. (Right side) : Fascia-lata aponeurosis, under the insertion of the same name. 



ANATOMY : DESCRIPTIVE AND SURGICAL. 77 

mine, succeeded in reducing the strangulation after long efforts, 
although he told the parents that to his mortification he had 
so enlarged the hernial rings, that the hernia could not be 
retained in the abdomen although he knew he had reduced it. 
The fact was, as I have since learned by personal examination, 
the boy was suffering from hydrocele as well as strangulated 
Hernia and the parts were dilated not so much by the doctor's 
manipulation as by the pressure caused by the effusion in the 
hydrocele. 

Since the symptoms of many other varieties of tumours so 
closely resemble hernial tumours, it will be necessary to dis- 
tinguish accurately between them in order not to be misled in 
our diagnosis. In surgical practice we have to distinguish be- 
tween the two forms of Inguinal Hernias, direct and indirect ; 
between Inguinal Hernia and the following conditions : — 

Femoral Hernia. Varicocele. 

Hydrocele of the cord. Hematocele. 

Hydrocele of testicle. Bubo. 

Sarcocele of testicle. Impacted faeces. 
Undescended testicle. 

We have also to distinguish between femoral Hernia and 

enlarged glands. 

Psoas abscess. 

Varix of saphenous vein. 

Lipoma of femoral canal. 

Ventral Hernia? may be confused with Umbilical, Thyroid 
with Perineal, Diaphragmatic Hernia? with Mediastinal Tumours, 
Congenital Hernia? with Hydrocele, and with Infantile or 
Encysted Hernia?. 

To make clear the different points of distinction between 
these various conditions, I have thought it best to arrange in 
tabular form the following differential diagnosis. 



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82 



HERNIA. 



The following diagrams illustrating the different forms of 
Hernia with some of the complications, are taken from my 
distinguished friend Thomas Bryant's highly esteemed work 
on Surgery, by his according me free permission for the uee 
of this work. The same permission is granted by my no less 
distinguished friend Mr. J. Wood. 

In all these diagrams the thick black line represents the 
parietes covering the hernial sac; the thin line the peritoneum 
and hernial sac ; the small body at the bottom of the sac the 
testicle. 






Fio. 10. 



Esq. 11. 



Fig. 12. 



Fio. 10. — This diagram illustrates the tubular vaginnl process of peritoneum open down to 
the testicle, ir.to which' a hernia may descend. When the descent occurs at birth the hernia is 
called "congenital ;" when at a later period of life the "congenital form," liirkett's "hernia 
into the vaginal process of peritoneum.*' or Malgaigne's "hernia of infancy." 

Fig. 11. — Tlv; same process of peritoneum open half-way down the cord, into which a hernia 
may descend at birth or at a later period. Birkett's " hernia into the funicular portion of the 
vaginal process of the peritoneum." 

Fig. 12. — The same process undergoing natural contraction above the testicle, explaining the 
hour-glass contraction met with in the congenital form of scrotal hernia as well as in hydrocele. 




« 




Fig. 13. 



Fig. 14. 




Fio. 15. 



Fig. 13.— Diagram showing the formation of the "acquired congenital form of hernia." the 
"encysted of Sir A. Cooper," •• the infantile of Hey," the acquired hernial sac being pushed 
into the open tunica vaginalis which encloses it. 

Fig. 14. — Diagram illustrating the formation of the "acquired" hernial sac, distinct from th*» 
testicle or YA^iintl process of peritoneum which has closed. 

Fig. 15. — Illustrates the neck of the hernial sac pushed back beneath the abdominal parietes 
with the strangulated bowel. See Figs. 11) and SJO. 



ANATOMY: DESCRIPTIVE AND SURGICAL. 



83 




£ Tl 





Fia. 16 



Fio. 17. 



Fio. 18. 



Fig. 16. — Shows the space in the subperitoneal connective tissue into which intestine may be 
pushed through a rupture in the neck of the hernial sac, the intestine being still strangulated 
by the neck. See Fig. 21. 

Fig. 17. — Diagram showing how the neck of the vaginal process may be so stretched into a 
sac placed between the tissues of the abdominal walls, either upwards or downwards, between 
the skin and muscles, — muscles themselves or between the muscles and the internal abdominal 
fascia, — forming the intra-parietal, inter-muscular or interstitial sac, hernia enbissac of the 
French, "additional" sac of Birkett. See Fig. 22. 

Fig. 18. — Diagram illustrating the reduction of the sac of a femoral hernia en masse with the 
strangulated intestine. First variety of displaced hernia. 





Fio. 19. Fia. 20. 

Drawing illustrating the second varieties of displaced hernia. 

Fia. 19. 

A portion of abdominal muscles, with the peritoneal lining. 
The strangulated fold of intestine. 
The testicle. 

The dark lines at the neck of the sac represent the duplicature of the peritoneum, 
which being unfolded formed a sac for containing the intestine when reduced. 



Fia. 20. 

A. Peritoneum lining the abdominal parietes. 

B. The tumour formed when the strangulated intestine was pushed through the spermatic 

canal into the sac formed by peritoneum in the inside. 

C. The superior portion of the intestine. 

D. The inferior. 

E. The scrotal hernial sac. 

F. The testicle, with the vaginal coat opened. See also Fig. 15. 



G 2 



84 



UEKNIA. 



33oiue.[> 



Lacerate cZJVecA: 
of 'hernial sctc 




Fig. 21.— Third variety. 

Interstitial hernia, with ruptured neck of hernial sac. See also Fig 16. 




Fio. 22.— Drawing illustrating the fourth variety or intra-parietai form of displaced hernia 

A. Peritoneum lining the aodominal muscles (B). 

C. Intra-parietal sac witn strangulated bowel. 

D. Scrotal hernial sac leading down to testicle (T). 

E. Director passed f r om the congenital scrotal sac through the internal ring. 

In the drawing the strangulated bowel has been introduced to make the description clearer. 

See also Fig. 17. 



CHAPTER IV. 
Strangulated Hernia. 

A Hernia is said to be strangulated when not only the passage 
of faeces is impeded by the constriction, but also the circulation 
of the blood. The varieties of Hernia in which strangulation 
is most violent and severe are the femoral and incomplete in- 
guinal, since they are small and therefore apt to be overlooked. 

A large and long standing Hernia is more liable to strangula- 
tion than a large and recent one, but a small recent Hernia is 
still more liable to strangulation than one of longer standing. 
Sir Astley Cooper says, " A small Hernia is more easily strangu- 
lated than a large one, the pressure on the contents being more 
violent and the symptoms much more urgent, as the stricture 
acts with much more effect upon a single knuckle in stopping 
its circulation, than when the contents of a Hernia are large and 
voluminous." On the other hand it must be borne in mind that 
of Herniae of the same size, an old one is more liable to strangu- 
lation than a recent one, although in the latter the symptoms 
are more dangerous and likely to be attended with mortification 
of the intestine. 

Is this condition of strangulation solely the result of a 
mechanical constriction, or is it partly the result of some 
pathological change set up in the intestine before protrusion ? 
Birkett feels justified from the symptoms preceding the con- 
striction, " in attributing the strangulated state of a Hernia to 



86 HERNIA. 

a predisposing cause, commencing in a morbid state of the 
alimentary canal generally ; at least in some cases." The 
patients have usually complained for some time of a disordered 
or relaxed state of the bowels, and it is also found that the 
entire mucous surface of the small intestines secretes more than 
a normal amount of their fluid, and that the intestines are 
greatly distended and congested. 

Erichsen on the other hand gives a slightly different aetiology 
of the Hernia. He thinks it induced by the constriction to which 
the intestines are subjected, producing stagnation of blood and 
inflammation of the congested part. 

The stricture is most commonly outside the neck of the sac 
in the tendinous structures surrounding it, although sometimes 
at the neck itself, and more rarely around the body of the sac, 
thus giving a Hernia shaped like an hour-glass. It takes place 
suddenly and usually in consequence of some violent muscular 
exertion. 13 

1. What is the condition of a Strangulated Hernia ? 

2. What changes take place in it ? 

3. What are the symptoms excited in the constitution, and 
the morbid conditions in the abdomen ? 

1. The first condition of strangulation is that the blood is 
impeded, and next that it is arrested. The tissues of the bowel 
become swollen, they are solid and leathery, their colour dark 
purple often mottled with red. This inflammation causes a flow 
of lymph into the intestines giving then a rough and villous 
appearance. 

When the bowels have been some hours strangulated their 
tissues become soft, the serous surface has lost all its normal 
characteristics, it is black and adhesive, gangrene has now set 
in. This state usually comes on within twenty- four hours, 
although it may come on in a very few hours or may be delayed 
for forty-eight hours. The intestine becomes firmly fixed to 



STRANGULATED HERNIA. 87 

the mouth of the sac by adhesions, the omentum becomes dark 
purple, and there is usually a large quantity of turbid serum in 
the sac. If the strangulation is unrelieved, gangrene of the skin 
may take place, and the f cecal matter may be discharged through 
the disintegrated tissues. Such a state is somewhat rare, and it 
is often the case that there is no external evidence that gangrene 
has attacked the intestines. 

2. As a result of the gangrenous inflammation an artificial 
anus may be formed in two ways ; one in which only a hole is 
corroded through the alimentary canal without interfering with 
its continuity, the other " due to an ulceration of all the coats 
of the bowel even to the mesentery," and therefore interfering 
with the continuity of the bowel. 1 

The coverings of the hernial sac undergo pathological 
modifications due to ecchymoses, inflammations, 11 oedema &c. The 
tumour may become very sensitive and excruciatingly painful ; 
it may also become swollen, from infiltration of serum, tense and 
regular in outline. 

" The discoloured parts become cold and insensible, and more 
and more dark except at their borders which are dusky red ; a 
thin, brownish, stinking fluid issues from the exposed integu- 
ments ; gas is evolved from similar fluids decomposing in the 
deeper-seated tissues, and its bubbles crepitate as we press 
them ; . . . . At the borders of the dying and dead tissues, if 
the mortification be stili extending, these changes are gradually 
lost ; the colours fade into the dusky red of the inflamed but 
still living parts; and the tint of these parts may afford the 
earliest and best sign of the progress toward death or the return 
to a more perfect life. Their becoming more dark and dull, with 
a browner red, is the sure precursor of their death ; their 
brightening and assuming a more florid hue is as sure a sign that 
they are more actively alive." 2 

1 See Chapter XI. 2 Paget, Surgical Diagnosis. 



88 HERNIA. 

Another appearance of mortified parts, characteristic of a class, 
is presented after they have been strangulated. I have mentioned 
the difference which in these cases depends on whether the 
strangulations have been suddenly complete, or have been 
gradually made perfect. In the former case the slough is very 
quickly formed, and may be ash-coloured, gray, or whitish, and 
apt to shrivel and become dry before its separation. In the 
latter case as best exemplified in Strangulated Hernia, the blood 
vessels become gradually more and more full, and the blood 
grows darker till the walls of the intestine, passing through 
the deepest tints of blood colour and of crimson, become com- 
pletely black. Commonly by partial extravasation of blood 
and by inflammatory exudation they become also thick, firm, 
and leathery, a condition which materially adds to the difficulty 
of reducing the Hernia, but which is generally an evidence that 
the tissues are not dead; for when they are dead they become 
not only duller to the eye, but softer, more flaccid and yielding, 
and easily torn like the rotten tissue of other mortified parts. 
The canal which was before cylindrical may now collapse ; and 
now commonly the odour of the intestinal contents penetrates 
its walls. 

I have said the serum might be turbid. It also becomes 
brownish yellow with the odour of faeces and before burst- 
ing though the walls of the intestine may infiltrate its tissues 
or coverings. 

3. One of the first and main symptoms of strangulation is nausea 
in the morning after rising from bed, with vomiting due to a 
nervous irritation upon the viscera. As soon as the strangula- 
tion has taken place the patient feels restless and uneasy, a 
feeling of tightness is felt as though a band were bound around 
the body. In general, the symptoms are those of obstruction. 
Around the seat of constriction there is acute pain, often 
increasing so as to resemble the severe pains of peritonitis. 14 As a 



STRANGULATED HERNIA 89 

result of the stoppage of peristaltic movements, complete con- 
stipation, severe and continuous vomiting together with violent 
retching, first ejecting the contents of the stomach and then 
frecal matter, and colic pains ensue. When the symptoms of 
peritonitis have appeared, the pulse is quick and hard, the mouth 
dry, surface of body hot and head racked with pain. The 
countenance assumes the peculiar shrunken aspect called by the 
name of Hippocrates, the extremities are cold, the mind is 
clouded with delirium, and when gangrene has set in hiccough 
comes on with a sudden cessation of pain. This symptom of 
hiccoughing is regarded as an especially unfavourable symptom. 
The period at which death takes place varies from three to five 
days, being earlier in small and recent than in large and long 
standing Hernia?. 

It is worthy of notice that strangulated omental Hernia has 
symptoms resembling strangulated intestinal Hernia, only they 
are less severe ; they lead however to the same result — fatal 
peritonitis. 

As in reducible so in strangulated Hernia there is need of a 
differential diagnosis. It may be confused with ilius but may 
be distinguished from it because in general the patient can tell 
the state of his bowels, there will be the history to help us and 
if we are to deal with a Hernia we can always with more or less 
search find a tumour. It may be confused with an obstructed 
irreducible Hernia but distinguished from it because the latter 
is not tender to touch and has no peritonitis. Although there 
may be constipation there is no vomiting as there is in 
strangulated. 

From an inflamed irreducible Hernia, because in it there is no 
vomiting and because the constipation is not entire, liquid fteces 
usually passing. 

From general 'peritonitis conjoined with Hernia, because in it 
the peritonitis is not confined to the region of the sac, because 



90 HERNIA. 

what little vomiting there is does not bring up faecal matter and 
because the constipation is not entire. 

With double Hernia, one may be strangulated and the other 
not ; the strangulated one will be the more tender about the 
neck of the sac, and thus we can determine in which the con- 
striction lies. 

m 

Displaced Hemice. — There are four varieties. The first ap- 
plies only to femoral hernias, the other three only to inguinal. 

First. The strangulated hernia with its sac may be bodily 
reduced within the abdominal ring and behind the abdominal 
parietes. This is the true reduction en bloc or en masse of French 
writers and of Luke. See Fig. 18. Cases are rare. 

Second. The neck of the sac becomes detached from the in- 
ternal ring and pushed upwards beneath the abdominal walls, 
so that the intestine is strangulated by the orifice of the sac. 
See Figs. 15, 19, and 20. The two latter drawings are the origi- 
nal ones of Sir Charles Bell, and first appeared in the Medical 
Gazette in 1828. A clinical report upon such a case may be 
found on p. 352. 

Third. This is an interstitial form with a ruptured or lacerated 
neck of the hernial sac. " The delicate serous membrane of the 
sac is rent or torn, and the hernia makes its escape through the 
aperture into the subserous connective tissue, as the effect of 
forcible or long sustained compression of the hernial tumor. Its 
course outside the peritoneal sac is advanced by continued pres- 
sure, and, detaching the connections of the neighboring peri- 
toneum, it forms for itself a pouch between that serous membrane 
and the internal abdominal fascia." See Figs. 16 and 21. This 
form is more common in the congenital variety of hernial sac, 
and occurs at the posterior part of the neck. 

According to Birkett, the indications of the accident are as 
follows : The tumor becomes flaccid, and therefore smaller. The 
bulk of the tumor slowly diminishes as the pressure is continued, 



STRANGULATION OF HERNIA. 91 

until at last very little, if anything, can be felt; but still the 
surgeon has failed to experience that sudden jerk so characteristic 
of the escape of the hernia from the gripe of the mouth of the 
sac. After the effects of the chloroform have passed away, all 
the symptoms of strangulated bowel recur, and perhaps with 
increased force. Even the tumor itself may reappear and recede 
on the application of slight pressure. When such a condition is 
found, the hernial sac must be exposed and opened. It may 
appear empty, and the finger may enter the cavity through a 
well-defined abnormal aperture, which may be mistaken for the 
internal ring and the cavity of the abdomen. This would, how- 
ever, lead to a fatal error, and one which would surely com- 
promise the life of the patient. Two orifices will be found; one 
dipping into the artificial sac, the other dipping into the abdomi- 
nal cavity. If the bowel does not come forth spontaneously, an 
effort must be made to draw it out, and then the true mouth of 
the sac will be discovered by passing the finger upward along 
the anterior surface of the mesentery. 

The protrusion is firmly constricted by the orifice of the her- 
nial sac. This constriction must therefore be cut, "after which 
operation the exercise of great care and caution is needed to 
prevent the entrance of the hernia once more into the abnormal 
space outside the peritoneal cavity. As the salvation of life 
depends upon the return of the protrusion through the natural 
orifice of the sac, considerable freedom in the use of the knife is 
justifiable." An interesting case, reported March 8, 1381, by 
Dr. E. Mason, of New York, will well illustrate this form of 
hernia, and may be found on p. 352. 

Fourth. This consists of an intermuscular or interstitial or 
intraparietal sac, with a herniated neck, and is almost always 
associated with a congenital form of hernia. The 3ac is usually 
found between the abdominal muscles and abdominal fascia, 
although sometimes between the external oblique and the skin. 



92 HERNIA. 

See Figs. 17 and 22. Anatomically, it consists of two parts ; 
that which passes along the inguinal canal into the scrotum, 
and that which is lodged in the wall of the abdomen. Scarpa 
and Fano have recorded cases. See also on p. 354 a case 
reported by Dr. Shrady, February 4, 1881. When the hernia 
is strangulated by the ventral orifice of the sac, and when it 
occupies the scrotal division, it may, unless very great care is 
used, be pushed by taxis into the other side, so that the tumor 
disappearing, the surgeon thinks the hernia reduced. The symp- 
toms, however, very quickly show that this is not the case. 

Birkett offers the following explanation for many of these 
cases. " The tissues of the scrotum are very loose, and readily 
change their position. Both the spermatic cord between the 
external abdominal ring and the hernial sac attached to the an- 
terior surface of the spermatic cord vary in length. When the 
hernia occupies the sac, the latter extends lower than when it 
is empty. Now let its mouth and neck be detached from the 
internal abdominal ring, and the hernia, still strangulated by 
the margins of the orifice, be pushed inside the abdominal walls. 
The fundus of the sac attached to the tissues of the scrotum is 
not on this account severed from these connections, but merely 
ascends toward the inguinal canal, and lies partially within it, 
with its walls in close contact, which, being rather thin, are not 
recognizable." 

All these forms of displacement are indicated by the disap- 
pearance of the tumor without the characteristic jerk, and by 
the persistence of the symptoms. The treatment in all is the 
same as that described under the third form. 



CHAPTER V. 

Operations for Hernia. 

"The radical cure of Hernia would be too important a triumph for 
surgery and a resource too deeply interesting to humanity to permit that 
we should not endeavour to improve it still more and to modify its pro- 
cesses and to make renewed efforts for the purpose of attaining this result. 
For myself I cannot cease to entertain the idea that in the experimental 
spirit of our age we may succeed in obtaining a remedy of this description 
which shall be of real efficacy." — Velpeau, Operative Surgery. 

In this brief and necessarily imperfect sketch of the various 
operations that have been or are now used for the relief and 
cure of Hernia, I have thought it best to insert without material 
alterations a paper prepared by me and read before the Vermont 
State Medical Society, June 15, 1880. With this brief explan- 
ation I trust the reader will kindly pardon any peculiarities of 
expression that may have crept into an essay intended to be 
delivered in an assembled meeting of medical gentlemen. 

As many of you are aware, I have written of late much 
upon the radical cure of Hernia, which has been received by 
the medical press and profession with no little interest. I 
therefore take the present opportunity to say that I do not 
like the term radical when applied to this or any other surgical 
operation. To me it sounds unprofessional, contrary to all my 
ideas of professional propriety and detrimental to the fair name 
of medical and surgical science. I know that some of the most 
honoured men that have brightened tbe pages of surgical litera- 



94 HERNIA. 

ture or that have taught in our universities of medicine have 
thus denominated many of the operations that have been 
devised for the treatment of Hernia. The term has been more 
extensively used, however, by those who are not of the regular 
profession and whose ideas of professional etiquette are not 
models for us to pattern after. I can but think then that in 
our present progress of the healing art, it would be out of 
harmony with the advancing march of improvement to retain 
the cognomen longer. If I have heretofore used the term 
radical it has been only to convey to the general profession a more 
distinct idea of the nature and possibilities of my operation. 
I now will gladly join hands with you of the profession in 
erasing from our vocabulary wherever we possibly can the 
word 'Radical Cure/ and I feel confident that under the less 
pretentious phrase, ' Cure of Hernia,' we shall accomplish just 
as successful results as with the more ambitious cognomen in 
general use. 15 

In presenting to your notice the various mechanical cures for 
Hernia, such as external compression, the application of sutures, 
of metals, catgut or silken cords, the insertion of goldbeaters! 
skin, the invagination of the external abdominal covering or 
any other device, whether herniotomy, tendinous irritation, or the 
actual cautery, I would have you take into consideration the re- 
marks of our distinguished and learned fellow and one of Boston's 
adopted sons and renowned operators as well as teachers in 
surgery. His remarks at our last February meeting of the Suffolk 
District Medical Society were that it was a well established fact 
and a true principle of surgery that all the operations that had, 
to his knowledge, been performed for Hernia had sooner or later, 
with hardly an exception, given way in a few days or years 
where a cure had been attempted by sutures or pins for the 
relief of the sufferer. There never were truer words uttered by 
any surgeon ancient or modern than these of Dr. D. W. Cheever, 



OPERATIONS FOR HERNIA. 95 

whose name shines brightly in the annals of our society and 
upon the pages of surgery. Words like these are comparable to 
the utterances of a Webster in constitutional law, and I take great 
pleasure in recording them. Well may the state of his nativity 
take pride in claiming such sons in medicine and law. But 
while his remarks, as well as those of Dr. Henry H. Smith, in 
his Principles and Practice of Surgery, are true of all previous 
operations for the relief and cure of Hernia, still we must 
remember that in all these operations a different irritation and 
a different amount of effusion is produced from that produced 
in the operation by injection now under consideration, and that 
by their methods of operation either the surrounding tissues are 
directly excited to absorb the lymph that has been effused or 
else they produce suppuration which is always fatal to the 
adhesive formation of lymph tissue whether this lymph is pro- 
duced on muscles or on tendons. 1 Even if by this new method 
of injection for cure there should be a tendency in the newly 
formed tissues to melt away, the process will be so gradual 
and will take place from such a superabundance of tissue 
(as has been fully borne out by experience) that nature 
will have sufficient opportunity to reassert her power and 
form afterwards out of the effused plasto-lymph as strong 
a tissue to say the least as ever originally existed around 
the rings. 

May we not hope then, with your generous efforts as well as 
those of the profession at large, to perfect this operation and 
present to the world a glorious exception to all the previous 
operations ? Who would not lend a helping hand to give this 
priceless gift to our fellow-men ? 

If I perform this or any other operation I wish, as any 
medical gentleman would, to do it well; but because I wish 
all this it is not necessary that I should make a specialty of 
curing Hernia only, nor need I feel, inclined to follow the 

1 See p. 205, 



96 HERNIA. 

example heretofore set by some to keep all of my doings in this 
operation from the light of the profession. My whole pro- 
fessional life, and all that is manly in my nature, revolts against 
pursuing any operation in the art of surgery or medicine in 
secret and apart from my professional associates for the purpose 
of selfish aggrandisement or personal gains. I do not believe 
in an idea of specialists in our noble, grand, old profession. 
The gentlemen who generally follow one idea and branch as 
a specialty are apt to become circumscribed in all of their 
professional reasoning and acts : if the specialty is that of 
the diseases of women, all their ideas of the suffering and illness 
of the fair sex are centred in the uterus and its appendages ; if 
the diseases of the eye, great opacity to every other ailment of 
the body. He who follows the treatment of the insane finds 
all insane except those who recover under his treatment. If 
Sir Henry Thompson removes stone from the bladder by a 
peculiar process of his own discovery, and does it successfully, 
he does not think it necessary that he should be interested only 
in the operation of lithophaxy ; or because Henry J. Bigelow 
may have thought to .improve the tube of Thompson, and to 
establish the toleration of the bladder to undergo prolonged 
operations, he does not operate for removal of stone only. "No, 
gentlemen ; those doing one operation exclusively, even if they 
do arrive at great perfection in it, lose their enlarged views on 
others that may be quite of as much importance as the single 
operation they perform. This is the reason we find Grsefe, 
and Agnew, or Williams, operators of distinction on the eye, 
taking as much interest in other surgical operations or in any 
improvement in medicine or hygiene as in their own depart- 
ment. By this study and interest do they not have better 
perceptions of all that pertains to all professional advancement ? 
You will also find Spencer Wells of England, Thomas and 
Barker of New York, and Brown Sequard of Paris, taking the 



OPERATIONS FOR HERNIA. 97 

same interest in other branches as in that "branch which they 
have so worthily developed and perfected by their study. In 
speaking thus, I would not have you think that I do not fully 
appreciate those who may have made a special study of any 
special branch of medical and surgical science, and that I 
intend to infer that we should not call such men to our aid 
and refer to them in any difficult operation requiring their 
peculiar operative skill. I do not, as is quite apparent, expect 
to do all the operations for the cure of Hernia, or overcome 
all the strictures of the urethra, or pass all the catheters of 
vermicular point into the human bladder. ISTo, I give freely 
my instruments and my method of performing these various 
operations and I feel confident that in them all will succeed 
quite as well as I have or even better. In this may I not look 
for your full approval and support ? 

What has been called a Radical Cure I A cure has been 
considered radical when the tendons, muscles, and fascia form- 
ing the barriers to the protrusion of the bowels are restored to a 
normal firmness and power of resistance. Such a cure is tested 
by the firmness of the rings and the absence of inconvenience 
and tenderness when the patient has returned to his usuai 
avocations. Hernia was formerly considered an immoral disease, 
and ever since the days of Hippocrates. Galen, and Celsus there 
have been constantly proposed new and pretended cures for this 
terrible affliction ; yet it would be manifestly unjust to condemn 
all cures indiscriminately simply because they were new and 
because they laid claim to a complete cure. Many of them are, 
however, so thoroughly empirical and absurd that the barest 
mention of them will be sufficient. The more scientific methods 
employed have been either to plug up the orifice by articles 
which will fuse with the surrounding tissues, or to produce such 
an inflammation of the parts as will provoke adhesions of the 
enlarged opening, and hence a contraction. Some of these 



98 HEIlNrA. 

methods are plausible, others probable, while others may justly 
lay the claim to fairly successful results. 16 

Among operations long ago obsolete, may be mentioned the 
' carat de'brique' of Fabricius, the vinegar bags of Verduc, the 
remedy of the Prior of Cabriere, which was an astringent 
plaster over the hernia and milk given internally, the method of 
A. Pare, which consisted of a cataplasm of iron filings with 
internal administration of diamond, Arnaud's decoction of dog- 
grass and laurel, the application of ammonium carbonate, as 
recommended by Belmas, &c. 17 

Compression. — Among the advocates of this well-known 
palliative remedy are Celsus, Theodorus Aetius, de Salicet, 
Norsia, Blegny, Trecourt, Petit, Juville, &c. Fournier, Beau- 
mont, and Duplat favoured the use of compression combined 
with the application of astringents, while in Germany some 
went so far as to recommend pressure to such an extent as even 
to form gangrene. 

Position. — This is too laborious a cure to be at all prac- 
tical or practicable, yet Eavin, Eiviere, de Hilden, Eeneaume, 
Arnaud, Fedran, Hey, and Rieck have soberly advocated a 
horizontal position in bed for six months with topical com- 
pression and astringents, together with low diet, blood-letting, 
and purging as insuring a prospect of recovery. 

Passing such unscientific procedures, we now come to methods 
of cure which rightly deserve the name of surgical operations. 
Some, to be sure, are more dangerous than others, while many, 
although now abandoned in their original form, have recently 
been revived in methods based upon them, but improved in 
various ways. These operations will include cauterization, 
incision, excision, ligature, suture, castration, scarification, dila- 
tation by organic plugs, acupuncture and closure of the rings 
either by wires or by injection. 

Cauterization. — This operation of laying bare the hernia. 



OPERATIONS FOR HERNIA. 99 

raising up the internal envelope without opening it, and cau- 
terizing the ring with a red-hot iron is spoken of by Avicenna. 
Franco was in the habit of laying open the sac and touching the 
neck with a button cautery. Among the cauteries that have 
been used we may mention sulphuric acid, muriate of antimony, 
potash, essence of euphorbium, ranunculus, &c. The object 
sought was to obtain an eschar around the neck and thus to 
cause a suppuration sufficient to produce new tissue. The 
cautery was applied by two methods, one directly to the 
hernial coats, the other indirectly from the interior of the sac. 
In the former method there is the serious inconvenience of not 
penetrating deep enough to accomplish our result, or if we do 
succeed in cauterizing the right parts, of injuring at the same 
time some important and vital organ, while in the latter the 
danger of injuring the viscera by the cautery is avoided by 
pushing them out of the way. 18 

" Incision. — This has been so popular a method that it was 
not until the latter part of the last century that it was aban- 
doned. 19 The hernial coverings, together with the sac, were first 
divided as in strangulated Hernia. The viscera having then 
been reduced the opening was closed by suture. But the 
results were fatal almost immediately ; and while Arnaud, 
Lieutaud, and Le Blanc favoured the operation, Acrel, Eichter, 
Sharp, Abernethy and others as strongly condemned it as 
formidable and dangerous. 

Just here it might be well to say that G. W. Hinman, of 
Deny, Vermont, recently reported one cure by opening the sac 
and brushing the inside with tincture of iodine, an operation 
which has in it some reasonable hopes of success. 

Excision. — This consists in dissecting and removing the 
sac, and involves such exceedingly great and almost inevitable 
danger of peritonitis, that although practised by Bertrandi, 
Lanfranc, Arnaud, Schmucker,Langenbeck and others of more 

H 



100 HERNIA. 

recent date, it is painful even to think of it. After this was 
done away came the method of cutting down upon the sac and 
introducing a ligature which prevented haemorrhage and did not 
expose, although it might involve, the peritoneum. 

Ligature. — Some have applied the ligature directly upon the 
sac by cutting dowu upon the parts; others apply it to the 
superficial integument. 1 Celsus speaks of those who placed the 
integument between two pieces of wood and pinched it so as to 
produce gangrene, while Saviard and Desault constricted the 
hernial envelopes so as to produce its mortification. 

It is recorded of Guy de Chauliac that in 1360 he laid bare 
the sac and then applied a ligature around its neck. Although 
this may be an operation to be preferred above cauterization, 
yet as it is essentially painful and dangerous in its liability to 
injure the peritoneum, it seems strange that in recent days it 
should be revived. An attempt was, however, made in 1872 in 
Paris and Lyons, by M. Martin, to rescue it from oblivion, and 
within the last thirty years by J. C. Nott, of Mobile, Alabama, 
who binds the columns together by a leaden ligature, at the 
same time compressing the sac, but taking care not to constrict 
or involve the spermatic cord. 

Suture* — Closely allied to the preceding method is the method 
of suture which is applicable especially to inguinal Hernia in 
males, and as it involves only the external ring, can be applied 
only to the direct kind of inguinal. Some accomplish the 
suture after a tedious dissection, but Thomas Wood of Cin- 
cinnati, Ohio, in 1851 passed a suture through both columns 
of the ring and bound them together by adhesive inflammation, 



1 This cure is especially applicable to young subjects. Although 
censured by Sabatier, Scarpa, and Sir A. Cooper, as producing convulsions 
and inflammation in children, it has been successfully used by Desault and 
Dupuytren. For an improved cure by ligating with carbolized catgut see 
p. 114 for Lister's antiseptic method. 



OPERATIONS FOR HERNIA. 



101 



taking care not to compress the sac. 1 The new tissue formed 
however in these cases has not been found sufficient to prevent 
the return of the Hernia. 

1 Essentially the same method has been used by G. Dowell, of Texas, 
who about 1859 performed the operation in the following manner: — The 
double spear-pointed needle (Fig. 23) being threaded with silver wire at 
one end, a portion of the skin and cellular tissue was pinched up over the 
hernia and the needle inserted and pulled through until the threaded point 
reached the superior tendon of the external ring. The sac was now in- 
vaginated and the needle passed through both superior and inferior tendons 




Fio. 23. — Dowell's Needles. 

of the ring. A second ligature was applied in the same way and both tied 
over a piece of cork, drawing the edges of the two tendons together. 

Another method by ligature is that recently devised by Octavius White, 
of New York, and soon to be given to the profession. The point A is 
invaginated into the ring. The needles are then pushed out through the 




•.?>.» „ — T,^ 

■Niemann & to. jT 



Fio. 24. 



integument and a ligature tied over the two handles and knobs C and D t 
these handles being turned over, as shown by the dotted lines. The 
needles are then withdrawn and the instrument, weighing less than an 
ounce, is left in place for some days. 

H 2 



102 HERNIA. 

S. E. Beckwith, of Cleveland, Ohio, also reports a process 
(May, 1872,) for the cure of recent inguinal and umbilical 
Hernias by a hare-lip suture. 

Castration. — Some of the operators by excision, ligature and 
crowding up of the sac, finding the operation too tedious 
enveloped the cord and sac by the same thread; from this 
originated castration as a method of cure. This was long ago 
interdicted by law, even by Constantine, although in very recent 
years many have boasted of the number of cases thus operated 
upon in secret. It is not only dangerous to life, unnecessary 
and barbarous, but it offers no hopes of a radical cure. 20 

Gilded Point. — To prevent the loss of the testicle, this 
operation was invented. It was used by Buchwall, in Denmark, 
and by Berault and A. Pare*, in France. It is practically the 
same as castration, although theoretically it avoided compressing 
the cord, compressing only the sac. 

Royal Suture. — This ancient process consisted in dissecting 
the sac and sewing it up without involving the cord. It is 
nothing more or less than suture applied to scrotal Hernise, and 
was fancifully called Royal by Fabricius because it saved the 
lives of subjects who if cured might protect the king in his 
royalty. 

After taking this cursory and synoptic view of the ancient 
operations, what surprises us most is not that the operations 
of excision, incision and exposure of the sac and ligature of 
the same were practised in ages gone by, but that they should 
be revived with all their suffering and danger by modern 
operators when safer and better means of cure lie near at 
hand. 

Scarification,— In this operation Le Blanc took advantage 
of the method of dilatation of the ring used for strangulated 
Hernia. 

It is, after all, only a variety of the incision method already 



OPERATIONS FOR HERNIA. 103 

mentioned and is open to the same dangers, although it is true 
that the effusion of lymph thus produced favours the con- 
solidation of the tissues and not their relaxation as Petit has 
claimed. Alphonse Guerin, the tenotomist, scarified sub- 
cutaneously, and compressed the abraded surfaces with the 
pressure of a truss. The operation, though plausible, is nearly 
useless, although Heaton sometimes resorted to it when supple- 
mented by his injection of quercus alba. 

Organic Plugs. — Of this method there are five varieties : 2J 



1. Plug of the Epiploon. 

2. Plugging with the t€ 

3. Plug of integuments. 

4. Plug with the invagi 

5. The two methods of Belmas. 



2. Plugging with the testicle or the sac. 



4. Plug with the invaginated skin. 



1. This applies to cases where we are dealing with an entero- 
epiplocele ; the epiploon or omentum may be inserted into the 
rings and compel them to contract so that the Hernia will not 
reappear ; Cooper, A. II. Stephens, of New York, Velpeau and 
Goyrand have in this way been successful in cures. The 
process is in some respects a natural one, but still has two 
inconveniences : it seems applicable only to strangulated Hernia 
and is liable to produce colic and traction upon the stomach. 
Besides it is not uniformly successful. 

2. The obstruction of the ring by the testicle is a useless 
operation advocated by Moinichen and Scultetus. Garengeot 
and Stiffen claim to have accomplished the same result by 
dissecting the sac and inserting it into the rin^s. 

3. Jameson, of Baltimore, reported in 1828 one solitary case 
of a crural Hernia upon a lady, cured in the following way. He 
cut down to the ring, cut from the neighbouring integuments 
near the ilio-pubic ligament a strip two inches long and ten 



104 



HERNIA. 



lines wide, which he succeeded, he says, in engrafting into the 
ring. Although painful, complicated, and somewhat dangerous, 
it has every reason in its favour theoretically, in small femoral 
Hernias. Practically, however, the fact of this reported cure 
is vitiated hy the circumstance that there was no professional 
witness of the operation. His only follower was Redfern 
Davies, of Birmingham, England, whose instrument (Fig. 25) 
and operation seem to be a complicated modification of Wurtzer s. 
He also w r as successful in his case. 




Flo. 25. — Redfern David's Instrument. 



4. This is the method of M. Gerdy and Signoroni performed 
in 1837, and modified by M. Leroy. Velpeau reports one 
successful operation in his practice. Gerdy reports about sixty 
cases, some of which failed utterly after a time. The adhesions 
formed are in fact too slight and tender ever to consolidate, and 
although it may not involve serious injury to the epigastric 
artery still it may produce dangerous and even fatal inflammation 
and peritonitis. It is principally adapted to the inguinal form. 
A fold of skin is pushed as far as possible up the sac, and held 
by two interrupted sutures introduced one third of an inch 
from each other by a curved double-threaded needle through 
the covering: tissues, the ends being; tied over a bougie. The 
cuticle of this pouch is then destroyed by ammonia, which 



OPERATIONS FOR HERNIA. 



105 



causes the inflammation that is supposed to work the cure. 
The suppuration produces adhesion about the eighth day, when 
the threads are removed. But when the threads were removed 
the plug often came out and with it the hernia came down. 
Gerdy used the finger for invagination, while Signoroni used 
a piece of catheter. It not only often failed of good Jesuits, 
but was also frequently fatal, as Thierry has shown. The 
principles of the operation have in a modified form done some 
service in the hands of other operators, e.^.,AVurtzer and others. 22 
D. Hayes Agnew, of Philadelphia, used an instrument (Fig. 2G) 
like a bivalve speculum, with which to invaginate the plug, and 
then embraced the base of the plug with a silver wire, which 




Via. 26 —Agnew 'a Instrument. 



could be removed after 10 — 14 days. This operation is no 
longer performed. 

Belmad Method. 1829. — The original operation consisted 
in the introduction and attachment of a small pouch of gold- 
beaters' skin to the upper part of the sac. The plastic material 
poured forth by the irritation produced by the presence of the 
foreign body spreads, involves this foreign body and forms the 
nucleus of an insurmountable barrier to the protrusion of the 
viscera. The operation was first tried upon dogs and with 
success. The first human subject operated on was easily cured 
by Belmas. He then induced M. Dupu) tren to undertake the 
operation. This was upon a boy of fourteen, whose life was in 



106 



HERNIA. 



danger for ten days in consequence of the operation, but who 
was radically cured after two months, not only of a congenital 
hernia, hut also of a hydrocele. Five cases in all were operated 
upon. Velpeau, who assisted in the last one, thinks the operation 
safe in itself, but provocative of remote dangerous symptoms. 

Belmas now modified his operation and deposited in the sac 
strips of gelatine or goldbeaters' skin, instead of pouches. These 
strips were introduced by a canula which can be separated into 
two halves within the hernial sac. This second method is pro- 
nounced by Velpeau as even less beneficial than that of Gerdy 
and is now entirely abandoned. 




Fig. 27.— Wui-tzer's Instrument 



Acupuncture. — A more simple method of cure was introduced 
by Bonnet, of Lyons, in 1836. It is called acupuncture, and 
consists in perforating the scrotum and sac near the rings with 
several pins, which are allowed to remain until they produce 
ulceration of the skin. M. Mayor of Lausanne, used a seton 
instead of a pin ; but whatever the modification, the method 
is useless since the whole canal is left open and the sac only 
imperfectly agglutinated. 23 

In 1838, Wurtzer, of Bonn, Germany, invented an instrument 
(Fig. 27) which carries out Gerdy's method of invagination simply 



OPERATIONS FOR HERNIA. 107 

and safely. His instrument consists of three pieces — a wooden 
(or, as now used, hard rubber) cylinder, a long curved needle 
and a concave wooden cover to produce adhesions. The cylinder 
is three inches long and three eighths to three fourths inches in 
diameter, according to the size of the Hernia, of a flattened 
shape, perfectly smooth and rounded upon the free end, a short 
distance from which is the orifice for the exit of the curved 
needle which runs through the cylinder, and is attached to the 
movable handle. The cover is to compress the folds of integu- 
ment during the operation and likewise has a hole in it for 
the needle. The protruded parts having been returned, the 
integument is pushed up the canal with the forefinger of the 
left hand, the cvlinder is introduced into the cul-de-sac thus 
made, the finger at the same time being withdrawn. When the 
end of the cylinder is in the internal ring, the needle is pushed 
through the sac, canal, and integument. The handle is then 
removed and the rest of the instrument allowed to remain in 
position 6 or 8 days. The puncture made by the needle sup- 
purates by the fourth day, the bowels are not allowed to move, 
rest is enforced, with a plain diet, and then a truss is worn for 
six months or more. Dr. Otto Weber, of Bonn, says, however, 
that of fourteen cases operated on by Wurtzer, not one was 
cured, for the rings are not closed and the, plug gradually with- 
draws. The failure is not due to peritonitis, but rather to the 
insufficient character of cellular or lymphoid tissue poured forth 
by the suppuration. Such tissue from its very nature never can 
be permanent, and is entirely different in this respect from that 
produced by irritation of the tendons by injection. 

This operation has been followed by Mosmer, by Kothmund, 
in Munich, Sigmund in Vienna, and by Spencer Wells in 1854, 
in the United States. 

Professor Armsby, of Albany, New York, has modified the 
operation by allowing a thread, which is occasionally moved to 



108 



HERNIA. 



produce inflammation, instead of a needle, to remain in the 
hernial sac and internal ring so as to cause the necessary sup- 
puration. Dr. J. W. Riggs, of New York, in March, 1858, also 
advocated the use of a seton, but on a larger scale, and reported 
several successful cures. 

JStill another modification is that of Dr. Hachenberg, of Day- 
ton, Ohio, who used an ivory ball threaded by a double thread 
to produce the suppuration. 

Since, however, the operations of Thomas Wood, Dowell, 
Wurtzer, and Gerdy, with all their various modifications, do 
not involve the internal, but only the external ring, they are 
not applicable to the oblique Hernise, whatever little may be 



^aSSSSS^ 




Fig. 28.— J. Wood's Operation. 

said of their probable or possible value in the relief of the 
direct variety. 

Operation of Wood, of King's College Hospital, London. 
This operation consists of the ' compression and closure of the 
tendinous sides of the hernial canal throughout its entire length ' 
(Fig 28). It differs from the older operations by being entirely 
subcutaneous, and by puncturing the sac only by a small 
valvular opening. The hernia being reduced, an incision 
through the scrotum is made by a tenotomy knife sufficient 
to introduce the forefinger and a needle. The fascia is then 
detached from the skin for the space of two square inches, and 
invaginated into the canal. The needle is now passed through 



OPERATIONS FOR HERNIA. 109 

the conjoined tendon, upwards and inwards through the internal 
pillar of the external ring. A wire about two feet long is 
introduced into the needle and drawn out through the scrotal 
aperture, one end projecting from the puncture above. Then 
with the finger placed behind the external pillar, this pillar and 
Poupart's ligament are raised from the deeper structures. The 
needle is now passed below the internal ring and through 
Poupart's ligament to emerge at the puncture already made in 
the skin and the wire drawn back into the scrotal puncture. 
The sac is pinched up and the cord slipped back from it as 
in taking up varicose veins. The end of the inner wire is now 
hooked to the needle and drawn back across the sac. Both ends 
of the wire are then twisted together into the incision so as 
to twist the inclosed sac likewise while traction upon the loop 
invaginates the sac up into the canal. This loop is then joined 
to the two ends of the wire in an arch beneath which is a stout 
pad of lint. After 10 or 15 days the wire may be withdrawn. 
It is reported that 65to70 per cent, of the cases thus operated 
upon have been cured, although many of them have returned 
to their original state after the lapse of several years." 1 

Operation of Dowell. — I here place my friend Dr. Dowell's 
operation, which he has very kindly written out for me, to in- 
sert in this work in his own words. 

Melrose, Mass, July 17th 18S0. 
" Dr. J. H. Warren : 

"Dear Sir, 

" Inclosed herewith I give you a synopsis of my 
suhcutaneous ligature for the radical cure of Hernioe. I com- 
menced the investigation of the cure more particularly in 1858, 
and continued these investigations until in 185D, 10th Sept. 
in the night and in bed, thinking over an operation with 
"Wmtzer's instrument I v/as going to perform next morning, I 

1 See p. 243. 



110 HERNIA. 

planned the entire operation as I now perform it with slight 
modifications as to the needle and other details which I will 
give you as briefly as I can. I started well with the idea 
to cure Hernia ; we must adopt some method by which we can 
restore the natural supports to the abdomen. That in operating 
for Strangulated Hernia it was often the case that within from 
one to two days the adhesions became so great that it was im- 
possible to separate them without cutting, showing that to get 
adhesions it was not necessary to fasten the surfaces brought 
in contact, that single contact with slight pressure would cause 
all peritoneal surfaces to unite. 

" The next question was how could we best do this, and at iast 
I projected and had made in 1866 by Messrs. George Tiemann 
and Co., New York, the needle shown in Eig. 23, p. 101, with 
an eye in each end, which I have changed since only by 
adding an eye at one end. The needle is made first with a 
groove from eye to eye, or rather from point to point to keep 
it from bending or breaking. The needle is from four to six 
inches long. At first I had it only three inches and the eye 
in the centre, but I found this too short, and the eye in the 
centre prevented the reversing of the needle which acts as 
a weaver's shuttle. 

"Operation. — I prepare my patient by having his bowels 
moved several hours before the operation and the urine voided 
before going on the operating table. The parts are then shaved 
of all hair and three lines made with a pencil or ink, one 
immediately over the centre of the tumour ; two about one or 
two inches on the sides of the first. Thus : — 




FlO. 29. 



OPERATIONS FOR HERNIA. Ill 

For left inguinal the needle is then threaded with some 
strong thread, I usually use wrapping twine used in the drug- 
stores. I thread only one eye and twist the thread hard and 
use it. I have from one to seven silver wire ligatures ready, 
and after putting all the threads in I think necessary I replace 
them with the silver wire. Thus prepared, the patient is put 
under ether or chloroform. I now take the unthreaded end in 
my right-hand finger and thumb while I pick up the skin and 
cellular tissues with my left hand to remove it from the sac and 
tendons. I then put the threaded point below my left-hand 
finger and thumb and run it through the elevated portion of 
the skin and cellular tissue until the unthreaded end rests on 
the tendons just under the line on the light or left as the case 
may be. At this stage, still holding the needle, the Hernia 
is invaginated and the left index finger is put in to guide the 
needle under the tendons and from one side to the other until 
I brins; out the unthreaded end in the line on the other side. 
I then pull on the unthreaded end until it gets loose above 
the tendons and then push back the threaded end to where I 
first started and the two ends of the ligature cross each other 
and are finally tied over a roll of adhesive plaster which I 
now mostly use. A bougie or piece of wood or cork will 
answer, it being fastened simply as a quill-suture ; but the 
adhesive plaster is soft and fits well, and I believe is the best 
thing I have used. I begin to put the ligatures in at the 
upper point of the rupture and continue them down until I have 
put in a sufficient number to close the rupture, using from one 
to seven according to the size of the opening. The ligatures have 
been left in from three to eight and some, in first case, fifteen 
days. The ligatures before tying are simply pulled up so as to 
close the wound, or bring its edges in contact with slight 
pressure ; if they are made too tight they will cause suppuration, 
and perhaps a failure, as all my failures suppurated and as I 



112 HERNIA. 

think by pulling the ligatures too tight. The ligatures are re- 
moved when I think I have produced sufficient inflammation 
to cause complete union, and this must be judged according to 
the case, but if no tendency to too much swelling leave them to 
seventh day at least. The bowels should again be moved before 
the ligatures are removed and a compressing bandage applied. 
Patient ought to keep quiet in bed for at least a week and avoid 
straining, coughing, laughing or anything that will press on the 
ring. I, last summer (1879), invented what I call my buggy 
spring truss to apply after these operations, to support the parts 
while they are tender and in all cases where the patient is 
only relieved. The spring is made rather thin and not very 




Fio. 80.— Dowell's Buggy Spring Truss. 

strong ; and two extra springs are put on over the main spring 
as the springs are fitted in a buggy {see Fig. 30). The 
whole is covered with soft leather, and adjusted over the 
rupture making only very light pressure while the springs 
prevent continuous pressure; but when there is a tendency 
to protrusion they become very strong and will not allow any 
protrusion sufficient to rerupture. This truss will be beneficial 
in the subcutaneous injection method as practised by yourself at 
the present. With the two methods subcutaneous ligature (by 
my operation) and subcutaneous injection as practised by your- 
self, with the aid of this truss, I sincerely believe all cases can 
be cured and without danger. The result of my operation 



OPERATIONS FOR HERNIA. 113 

so far as I can learn is about as follows : one hundred and three 
cases treated by myself; twenty-four cases partially relieved, two 
cases reported as made worse, one child died in seven days 
after operation, with congestion of the brain, but no doubt the 
chloroform and operation had something to do with the 
development of the fever which was of the malarial form 
of congestion of the brain. Cures seventy* six. So far as I 
know all these remain well, some have had partial return of the 
Hernia and wore trusses. Several were operated on twice and 
failed, both times; I know no particular reason for the failures 
except the ligatures were put in too tight. The ligatures should 
be carefully cut just under the knot and at one side of the knot. 
If cut on the side or the knot cut off, when the quill is removed 
the ligatures become buried and cannot be removed, and have 
suppurated and caused a great deal of pain, and in almost every 
case a failure. This is a little thing, but is one of the most 
important in the whole operation. When the patient suffers 
any pain I give full doses of morphia and apply cold cloths 
or astringent washes with morphia over the ligatures. Where 
there is no pain I simply put a piece of lint over the ligatures 
and saturate it with collodion. 

"The operation above has been performed about two hundred 
times by different operators. Drs. Wilkerson and Trueheart, of 
Galveston, Texas ; Drs. Worthington and Bibb, of Austin, 
Texas ; Dr. Powell, of Florence, Texas ; Dr. Kuskin, of Groes- 
beck, Texas ; Drs. Allis and Hunter, of Philadelphia ; Dr. 
Johnson, of Eichmond, and many others. Their exact statistics 
are not at hand, but I believe they have had equal or even 
better success than myself, as I included in my list all the cases 
operated on in my experiments to perfect th-e operation. My 
greatest fear was of general peritonitis, but this has not hap- 
pened in any case of mine. Some ask, do you inclose the 
spermatic cord in the ligatures ? No, never ; it is ke^t below the 



114 HERNIA. 

ligatures by the invaginating finger. The subcutaneous injec- 
tion is specially useful in Hernias of small size and recent date, 
while the subcutaneous ligature is suitable to large Hernia and 
of long standing, and, as I believe, contains the only principles 
of success in Hernias large and of long standing. 
" Yours most respectfully, 

" Greensville Dowell, M. D." 

Antiseptic Use of the Carbolised Catgut Ligature. — With 
the consent of the author, Dr. Henry 0. Marcy, of Cambridge, 
Mass., I reprint from the Transactions of the American Medical 
Association, 1878, the following essay : — 

"October 11, 1871, I read a paper before the Middlesex 
County Medical Society, which was afterwards published in the 
Boston Medical and Surgical Journal, November 16, 1871, page 
315, entitled ' A New Use of Carbolised Catgut Ligatures.' I 
there reported the two following cases, operated on for Stran- 
gulated Hernia. 

"Case I. 'On the 19th of last February I was called in 
consultation by Dr. A. P. Clarke, of Cambridge, to see Mrs. M., 
aged sixty, who had for years suffered from Hernia. Five days 
previously she had been seized with severe pain in the inguinal 
region, accompanied with vomiting, and had been confined to 
her bed since that time. 

" ' Long-continued and careful taxis had failed to reduce the 
hernia ; and for twenty-four hours the vomiting had been ster- 
coraceous, and the patient seemed in extremis. The hernial 
tumour was the size of an egg, protruding from the external 
inguinal ring. A careful dissection exposed the sac, which was 
closely adherent to the surrounding parts. The constriction 
was in the ring, bounded below by Poupart's ligament, and 
above by the transversalis fascia and conjoined tendon. 

" ' The stricture was divided in the usual way, with the 



OPERATIONS FOR HERNIA. 115 

hernial knife carefully introduced upon the finger. This was 
accomplished with some difficulty, owing to the constriction of 
the ring. The sac, unopened, was then pushed up with its 
contents into the abdominal cavity, and two stitches of medium- 
sized catgut ligature were taken directly through the walls of 
the ring. The wound was dressed antiseptically, and from Dr. 
Clarke's notes, taken at the time, I find that the patient com- 
plained of no pain, steadily progressed without accident, and 
was discharged, convalescent, March 12th, three weeks after 
the operation. 

" ' The wound did not close entirely by first intention, but a 
careful daily examination showed no trace of the ligatures, and 
an abundant deposition of new tissue could be felt in the line 
of the opening about the walls of the ring. The result was a 
radical cure of the hernia, and a firm, hardened deposit may 
still be felt marking the closure. The ligatures were first 
suggested to my mind, because the patient suffered severely 
from an asthmatic cough, and it was at least desirable to secure 
a temporary strengthening of the weakened ring.' 

" She died six years after the operation, and was troubled with 
the cough during the entire period, but had no return of the hernia. 

" Case II. ' Mrs. L., aged forty -five, had been very much 
reduced by excessive menorrhagia, and upon March 10, 1871, 
my attention was called to an old, direct inguinal hernia of the 
left side, usually supported by a truss, which had come clown 
the night previously and defied the patient's efforts to replace. 
After two attempts to reduce the hernia under ether had failed, 
assisted by Dr. W. W. Wellington, of Cambridge, I operated 
as in the first instance, dividing the constricting ring and 
replacing the sac and its contents unopened. Three carbolised 
ligatures were applied through the walls of the ring, and the 
wound was carefully dressed with carbolised lac plaster. 

" ' As in the first case, there was complete absence of pain, 

I 2 



116 HERNIA. 

the wound united without suppuration, there was an abundant 
deposit of new material about the ring, and when last 
examined in June, the cicatrix was linear, but a firm, hard 
deposit of new tissue could be felt marking the site of the 
sutures. 

"' On the 7th of April my attention was called to the wound 
by the patient, who felt a slight uneasiness, and I discovered a 
small swelling in the cicatrix about the size of a bean; this, 
upon being opened, discharged a drop or two of pale, serous 
looking fluid, which microscopic examination proved free from 
pus cells, but it contained a few shreds of connective tissue, 
which appeared to be minute portions of one of the ligatures. 
The cure is radical, and in neither case has the patient used a 
truss since the operation/ 

" I then say, as far as my observation has extended, this is a 
new use of the carbolised catgut ligatures, and suggests a still 
wider field for application. "No method of operation for radical 
cure of Hernia appears more feasible, is probably attended with 
less danger, and at the same time affords a means of closing 
and strengthening the weakened ring, which is so desirable, and 
yet, with all the ingenious devices of surgery, is so difficult to 
obtain. As perhaps might have been expected, the article 
attracted very little attention, written by a young man fresh 
from his European studies and an ardent admirer of Professor 
Lister, whose views at the time, I believe, were not accepted by 
a single surgeon in the Boston district. 

" In these days of improved means for the reduction of Hernia, 
by the use of ether, by aspiration, and by rest with .the hips 
higher than the shoulders, with the ice-bag applied locally, the 
surgeon in private practice is called upon to operate for the 
relief of Strangulated Hernia much less frequently than formerly. 
As far as I remember, T have operated for Strangulated Hernia 
only four times since the publication of this paper, and these 



OPERATIONS FOR HERNIA. 117 

cases were treated substantially as those above given. The last 
case, inasmuch as it affords the opportunity of showing the 
result anatomically, merits a careful study, and causes me to 
bring the subject to your attention now. 

" Mrs. W., aged seventy, had been for many years an invalid 
from double inguinal Hernia, the right side being of such pro- 
portions that, after many endeavours to retain it by a truss, 
this appliance had been thrown aside as useless. On the left 
side was an irreducible omental hernia, at times complicated 
by the escape of a loop of the intestine through the ring. 
Nausea and vomiting had persisted for thirty -six hours before 
the operation. 

"As usual, antiseptic precautions were used, with carbolised 
spray and careful dressings. After slightly enlarging the ring, 
the intestine was easily reduced, but the omental portion, the 
size of a small orange, presented a number of bleeding points 
upon its being unravelled, and was adherent to the walls of the 
ring. Because of this, the whole mass was tied with catgut 
and removed, the ring was carefully closed with catgut sutures 
of a large size, No. 2, I think, five in number. The wound 
healed by first intention throughout. Temperature never 
exceeded 99° F. 

" The patient suffered no pain, and made a perfect recovery. 
She was allowed to get up in two weeks, and never wore a 
truss. She was so much pleased with her happy escape from 
danger and her complete cure that she besought the privilege of 
being operated upon for the radical cure of the right side. I 
tried again a series of trusses, but to no avail, and after careful 
reflection consented to perform the operation. This took place 
February 4, 1878. The abdominal wall was thin, the ring 
extremely large, and its pillars were attenuated. The sac was 
readily returned unopenH, and sutures were used as upon the 
other side, perhaps eight in number. I included in my stitches 



118 HERNIA. 

as much tissue as possible, but at the close of the operation felt 
the cure less satisfactory because there was so little material to 
fill in and support the weakened ring. 

"The union was entirely by first intention, leaving, as before, 
a linear cicatrix which never suppurated. There was no eleva- 
tion of temperature, and the patient made a rapid recovery. 
During the first week there was considerable swelling of the 
tissues about the ring; these parts were slightly tender upon 
pressure ; and, what I believe to have been the thickened 
returned sac could be felt through the attenuated relaxed 
abdominal walls. The patient was kept in bed three weeks ; 
but upon being permitted to get up it could be easily seen the 
cure was not complete, for there was impulse on coughing and 
a slight protrusion through the ring. She was fitted with a 
light truss, which easily retained the hernia, and was allowed to 
go about the house. She died suddenly, April 17, 1878, and 
the autopsy revealed an aneurism of the internal carotid of the 
right side, which had given rise to scarcely any symptom, 
except a gradual loss of vision of the right eye, but its 
existence had not been suspected. 

"The specimen here presented shows the walls of the ring 
much thicker than before the operation, and its calibre dimi- 
nished perhaps two-thirds. A light truss would probably 
have been sufficient easily to hold the parts in their proper 
relations. 

" The use of animal ligatures in surgery is by no means new. 
In all probability catgut, the form of animal thread or ligature 
which has been most frequently used in modern times, was 
employed as surgical sutures eight or nine hundred years ago. 
The celebrated Arabic writer, Rhezieus, who practised in Bagdad 
about a.d. 900, speaks of stitching up wounds of the abdomen 
with a thread made of the string of a lute or harp; and another 
Arabic author, Albucasis, who lived a century or two later, 



OPERATIONS FOR HERNIA. 119 

alludes in the same class of injuries to stitching a wounded 
bowel with a fine thread made of the twisted intestine of an 
animal. The strings of the ancient Egyptian harp, and hence 
probably of the Arabic, were made of catgut. Homer, in the 
Odyssey, speaks of the strings of the old Greek harp as made 
of the twisted intestine of the sheep. 

"To Dr. Physick, of Philadelphia, is undoubtedly due the 
honour of having first introduced animal ligatures into surgical 
practice. His ligatures were made of chamois leather. Silk 
may be considered an animal product, but however used, even 
when carbolised and inclosed in a wound which readily heals 
by first intention, the softened fibres usually act as an irritant, 
and are later discharged by the processes of suppuration 
Animal tissues made but indifferent ligatures; and were 
practically long since abandoned. They were soft, slippery 
upon being immersed in water, and were by no means strong. 
. " To Professor Joseph Lister we are indebted for a most im- 
portant modification of the catgut ligature. In his enthusiastic 
devotion to his new ideas of the possible repair of tissue, lie 
had observed that, under antiseptic dressings, clots of blood and 
large pieces of dead skin and other tissues had disappeared 
without suppuration ; therefore he inferred that small pieces 
of animal texture, if applied antiseptically, would be similarly 
disposed of. To make cutgut antiseptic, he immersed it, as 
prepared for the violin, in a strong watery solution of carbolic 
acid, and noticing the changes which followed in its texture, 
after considerable variety of experiments, he gave us the ligatures 
as at present used. They are prepared by immersion of the 
gut in a mixture of five parts of fixed oil, olive or linseed, 
to one part of xhe crystallized acid, liquefied by the addition of 
five per cent, of water. After a few weeks' suspension in this 
fluid, the catgut becomes translucent, firm, hard, but moderately 
pliable, makes a strong knot, and upon immersion in water or 



120 HERNIA. 

the fluids of the body, it undergoes no immediate change, and 
for days together the knots retain a firm hold. 

"To show the importance of the proper preparation of the 
ligature, I quote from Professor Lister's original paper, published 
in the Lancet, April, 1869 : ' But for the sake of surgeons who 
may wish to prepare it for themselves, it is necessary to 
mention, in order to avoid disappointment, that the essence of 
the process is the action of an emulsion of water and oil upon 
the animal tissue. The same effect is produced upon the gut, 
though more slowly, by an emulsion formed by shaking up simple 
olive oil and. water, as by one which contains carbolic acid. 

" ' On the other hand, an oily solution of carbolic acid without 
water has no effect upon the gut beyond making it antiseptic, 
and if water be added only in the small proportion which the 
acid enables the oil to dissolve, though the gut is rendered 
supple, and acquires a dark tint from the colouring matter of the 
oil, it will be found, even afcer steeping for months in such a 
solution, that when transferred to water it swells up and 
becomes soft, opaque, and slippery, as if it had not been sub- 
jected to any preparation. How it is that an emulsion produces 
this remarkable change in the molecular constitution of the 
tissue I do not profess to understand. I was at first inclined 
to regard it as a closer aggregation of the particles, brought 
about by a kind of slow dying of the moistened gut in the oil, 
as the watery particles precipitate to the bottom of the vessel ; 
but, not to mention other circumstances opposed to this view, 
the oil remains turbid for a very long time, the finer particles 
of water being extremely slow in precipitating, and if, after the 
lapse of weeks, a piece of dry unprepared gut is suspended in 
it, the thread is soon rendered soft and opaque by the very 
liquid in which gut which has been longer immersed is growing 
constantly firmer and more transparent. 

" ' It is necessary that the gut be kept suspended so as not to 



OPERATIONS FOR HERNIA. 121 

touch the bottom of the vessel, for any parts dipping into 
the layer of precipitated water would fail to undergo the change 
desired. 

" ' The vessel containing the emulsiou should be kept undis- 
turbed, for if the water is shaken up with the oil the process is 
retarded. An elevated temperature, of about 100° F., seems 
for a while to promote the change, but ultimately leaves the 
gut in an unsatisfactory state compared with that obtained at 
an ordinary temperature ; and conversely, some portions of gut 
which I have prepared in a room without a fire, in cold weather, 
at a temperature of about 46°, were in one week already in a 
trustworthy condition for surgical purposes. Hence the gut 
should be prepared in as cool a place as possible. The longer 
it is kept in emulsion the better the gut becomes. I once 
feared that in time it might grow too rigid for convenience, 
and possibly brittle also ; but experience shows that this is 
not the case. 

" ' When removed from the emulsion it soon dries in the air, 
but retains a considerable portion of its carbolic acid for several 
hours, so that no apprehension need be entertained of loss of its 
antiseptic property from exposure during the performance of 
an operation. In course of time it loses all the carbolic acid 
also, but retains permanently its altered molecular condition. 
If thus kept dry, as may prove the most convenient for the 
manufacturer on a large scale, it must be steeped thoroughly 
in some antiseptic lotion before its use. And for the surgeon 
the most convenient way will probably be to keep it always in 
the antiseptic emulsion, so as to be ready for use whenever 
it is required/ 

" Dr. D. W. Cheever, of Boston, writes me under date of 
May 14, 1878 : ' I tried catgut for a radical cure of Hernia, but 
it was speedily absorbed and failed.' He is unable to give me 
particulars with regard to the use of the ligatures. 



122 HERNIA. 

" Dr. J. C. Warren wrote me a few day since : ' I should fear 
that they would not hold long enough to keep the parts in 
apposition until union becomes firm. We have given up their 
use at the Massachusetts General Hospital for this reason : they 
do not hold longer than four days.' 

" I believe there are distinct limits to the usefulness of the 
catgut ligature, and if our profession early learns to know what 
these limits are, not only may the lives of our patients be 
iess endangered, but an aid to surgery which now promises 
much of good will be rescued from wholesale condemnation and 
oblivion. In plastic operations, especially of mucous tissues, I 
would never think of using catgut ligatures. 

"In wounds exposed to the air, or liable to suppuration, 
where the ligatures are soaked in fluid secretions, I am well 
aware the catgut knot is liable to become loose; but in the 
antiseptic ligation of vessels, or the closure of deep-seated 
tissues, it is far superior to any other. Here, when properly 
applied, it is open to few of the objections made. Owing to 
the firm character of the material, circulation of the inclosed 
part is more liable to be impeded than with silk ligatures, and 
hence care should be exercised; but within the limits here 
assigned, an experience of eight years justifies their use. 

* Judirinsr from mv own observation I am inclined to believe 
the ligature properly, that is antisepticaliy, used is not absorbed 
at all, but is changed particle by particle, being in this way not 
revitalised but replaced by living tissue, thus producing a rein- 
forced band of new connective tissue in place of the ligature 
itself. 

" The specimens here shown I think demonstrate this. The 
one last operated on, February 5th, death taking place April 
17th, namely, sixty- eight days after the operation, shows un- 
mistakable thickening of the connective tissue about the ring ; 
and there are yet seen, although preserved in a bichromate of 



OPERATIONS FOR HERNIA. 123 

potassa solution, hence less distinctly than at the autopsy, traces 
of the ligatures. These are of a darker colour than the sur- 
rounding parts, retain imperfectly the shape of the ligature, and 
are of considerably greater density and firmness. Under the 
microscope they show only wavy bundles of connective tissue. 
In the older specimen operated on December 2d, after the lapse 
of four or five months, you can no longer trace constricting 
fibres in the shape of circumscribed bands, but you will find a 
firm reinforcement of the parts by connective tissue which 
certainly includes the walls of the ring, and hence we infer 
it is developed about, or transformed from the ligatures them- 
selves. This quite accords with Mr. Lister's experiments in 
the ligature of arteries. 

" From the article previously mentioned I quote as follows 
' Thirty days after the operation, the animal, a calf, which had 
continued in perfect health, was killed, and the parts removed 
for examination. On dissection I was struck with the entire 
absence of inflammatory thickening in the vicinity of the 
vessels, the cellular tissue being of perfectly normal softness 
and laxity. On exposing the artery itself, however, I was at 
first much surprised to see the ligatures still there, to all ap- 
pearance as large as ever. But from my other experiments, it 
might have been anticipated that the ligatures of peritoneum 
and catgut placed on the calf s carotid would, after the expira- 
tion of a month, be found transformed into bands of living tissue. 
Such was in truth the case, as was apparent on closer examination. 

" Mr. Fleming published in 1876, in the Lancet, a series of 
observations upon the 'behaviour of carbolised catgut inserted 
among the living tissues,' and gives his results confirmatory of 
such change. 'A softening takes place from without in, the 
catgut breaking down and becoming infiltrated with cells. The 
mass into which it lias been converted begins to metamorphose 
and is soon permeated with blood channels, and ultimately may 



124 HERNIA. 

be described as a cast of the catgut in a kind of granulation 
tissue, freely supplied with blood-vessels, which in many of 
my sections are easily injected.' These views should not seem 
exceptional, when we remember many well-known facts, for 
example, that the revivifying of skin dead at least by separation 
for a considerable period, as in that from an amputated limb, 
goes on so uniformly that transplantation of it upon granulating 
surfaces, and these not best fitted for its growth, has now become 
a daily practice in surgery. 

"Even the epithelial cells removed by a considerable distance 
from the circulation, and already dead, thus live again, and 
multiply so rapidly as to be of practical use in the repair of 
large denuded surfaces. The periosteum, as Oilier and others 
have shown in their experiments, may be also transplanted, and 
not only live but become an active factor in the reproduction of 
bone ; and teeth have been removed, filled, and replaced, actually 
transplanted to other locations, and regained their lost relation- 
ship of nutrition. 

"The spurs of the cock, as observed by Baronius, when 
transplanted to the comb, not only ]ive, but remarkably increase 
in size, and when ingrafted into the ears of oxen, as is practised 
in Mexico, they attain a size truly wonderful. 

"Mantegazza described and figured one of these spurs, which 
in its dry state weighed nearly one pound (396 grammes), was 
twenty-four centimetres in height, and twenty centimetres in 
width. 

" If such wonderful activity of reproduction and growth are 
shown by these tissues, there would appear to be no reason why 
the cells of the fibrous tissues might not also undergo changes 
in nutrition equally remarkable, of which practical advantage 
may be taken. 

" This is not the place, nor have we the time for a careful 
review of the history of the various devices suggested for 



OPERATIONS FOR HERNIA. 125 

the radical cure of Hernia. For centuries this has been a 
prolific field for charlatans and for quacks of every description. 
Hernia-curers roamed over Europe a century ago, practising 
castration and various reckless and dangerous devices, at 
the cost of many lives, and, it is needless to say, with the 
performance of few cures. 

" Within the present century many of the best surgeons have 
given this subject careful study, and some of the most ingenious 
of surgical devices have been brought into requisition. Nearly 
all of them have sought to accomplish a cure by one of two 
ways : either by producing adhesive inflammation and oblitera- 
tion of the sac, or by producing closure of the ring. Monsieur 
Bonnet inclosed the cord between pins fastened to rulls of linen. 
Geidy plugged the ring with invaginated skin held by stitches, 
and afterwards with the object of correcting the tendency of 
the invaginated skin to be withdrawn, cut it free, and ended 
with a plastic operation, by raising a flap from below. This 
method was often successful in his hands, but its complication 
and dangers prevented its general adoption. 

" Belmas invented an instrument, consisting of a canula with 
stylets. Through the passage in the canula threads of gelatine 
were to be introduced and be ultimately absorbed, after having 
produced the requisite adhesive inflammation. Then he applied 
a truss. 

"The operations of Velpeau, Wiitzer, and Wood are better 
known. Mr. Wood operated about two hundred times, with 
the result of three deaths and about seventy-five per. cent, of 
reported cures. Acupuncture, a revival of the punctum 
aureum of the ancients, as practised by Dr. Pancoast of Phila- 
delphia, though unsuccessful as a means of cure, suggested to 
him, as well as to Dr. Young of Tennessee, the use of subcuta- 
neous injections of iodine or cantharides into the sac. A 
number of successful cases thus operated upon are reported. 



126 HERNIA. 

" This method was practised for many years as a secret cure by 
Dr. Heaton of Boston, with reported success. Eecently he has 
published a monograph upon Hernia, in which he gives a de- 
tailed account of his treatment and experience. He reports a 
large number of cures, and claims that his method is devoid 
of danger. It consists of a fluid extract of white oak bark 
injected with a hypodermic syringe into the sac. 1 This method 
has been tried with moderately successful results at the Boston 
City Hospital. By means of it, a considerable amount of 
thickening and narrowing of the ring is certainly produced. 

" In 1858 Dr. Gross, in two cases, cut down upon the ring and 
brought together its walls with silver sutures. A cure followed 
in both cases. In 1871 Dr. Van Best reported three cases 
operated on for radical cure by a subcutaneous sewing of the 
ring with salmon gut. Two of these cases were successful. 

" Dr. G. Dowell, professor of surgery in Texas Medical College, 
published a treatise on Hernia in 1877, and describes a new 
method for its radical cure. He there reports sixty- eight cases 
with sixty permanent cures, and at the date of this publication, 
he informs me the number of his operations exceeds one hun- 
dred. By a needle of peculiar construction he subcutaneously 
sews the pillars of the ring with silver wire. The testimony of 
such an indefatigable student, with his very large experience 
and remarkable results, is of the greatest value. 2 

" Mr. Charles Steele, of Bristol, reported in the British Medical 
Journal, November 7, 1874, a successful case of radical cure of 
Hernia, which was operated on precisely as were my own cases. 
The patient was a boy of eight. The surgeon used two stitches 

1 The operation has often been thus misunderstood. The needle was not 
an ordinary hypodermic syringe but had a blunt needle with two orifices 
near the end, so that the fluid might be thrown at right-angles upon the 
rings and not into the sac. — J. H. \V. 

2 Dr. D. informs me, July 3rd, 1880, that he succeeds in 75 per cent, of 
his cases. — J. H. W. 



OPERATIONS FOR HERNIA. 127 

of catgut antiseptically, and union followed by first intention. 
After six months the hernia returned, and the operation was 
repeated. A truss was applied for safety. A perfect cure was 
effected, in the judgment of the operator, a year later. 

" Nearly all the late writers on surgery, such as Bryant and 
Erichsen, deprecate any attempt to secure the radical cure of 
Hernia, except in severe cases ; and Mr. Bryant regards the 
supposed elongation of the mesenteric ligament as a probable 
cause of the imperfect results obtained by various operators, but 
he supports his proposition neither by theory nor by fact. If 
the operation which I have proposed is done properly, with 
antiseptic caie, I believe that to a great extent it is devoid of 
danger. In a series of papers upon Strangulated Hernia, based 
upon one hundred operations performed by himself, published 
in the British Medical Journal for 1872, Sir James Paget, in 
advocating the replacing of the sac unopened, if possible, says : 
1 The structures divided externally to the sac are insignificant ; 
and it might be difficult to name an operation less endangering 
either life or health than this would be. The peritoneum is not 
wounded ; the intestine or omentum is not touched or exposed 
to the air ; the wound may be small ; any haemorrhage may be 
easily stayed and must be all external. Thus the wound is 
favourable to speedy healing, and erysipelas, or any other 
mischief, is not likely to extend to the peritoneum.' 

" I would not appear over sanguine in the suggestion of any 
new method for the radical cure of Hernia. I am perfectly 
aware that this has ever been one of the most troublesome and 
unsatisfactory problems in surgery ; and my experience has 
been too limited to prove little except possibilities. 

" However, I must claim a favourable consideration, on a legi- 
timate field, for the use of the carbolised catgut ligature, at 
least in all cases of Strangulated Hernia where the wound can 
be closed. This method does not add to the dangers of the 



128 HERNIA. 

operation, and is probably followed by a cure. In comparing 
the operation with that usually recommended, of subcutaneously 
stitching the ring with sutures of any material, it seems appa- 
rent that to cut down upon and expose the ring gives a much 
better opportunity of carefully closing it, refreshing its borders, 
and thus avoids injury to the spermatic cord, while it does not 
increase the danger of the patient." * 

Injection. — This method marks an epoch by itself in the 
history of the radical cure of Hernia. Velpeau is, without 
doubt, the first who ever injected for the radical cure, and says 
that " sensible like other practitioners of the want of a radical 
cure for Inguinal Hernia, and convinced, moreover, for a long 
time that we were wrong in abandoning indiscriminately all the 
trials which had this object in view, I also have endeavoured to 
arrive at it by a special method. The process which I have 
proposed is the same as that which is employed for the radical 
cure of hydrocele." In the early part of 1835 he had already 
conceived the idea of applying injections to the cure of Hernia, 
and in February and July, 1837, he performed successfully and 
without difficulty, the operation upon Hernias with an iodine 
injection, first, however, cutting down upon the parts, but at the 
same time being very careful not to allow any of the injecting 
fluid to penetrate the peritoneal cavity. The injection was 
administered with "the canula of the trochar guided upon a 
blunt-pointed probe." 

We find also that my esteemed and honoured countryman, 
the late Dr. Pancoast of Philadelphia, cured thirteen patients in 
1836, and that later my beloved friend, the late Dr. J. Mason 
Warren of Boston, injected sulphuric ether with success. In 
1846, Dr. W. H. Roberts of Alabama made his first hypodermic 
injection for Hernia with oil of cloves. His idea of this opera- 
tion had been derived from a Dr. Woogencraft, as I am informed 
by Surgeon Billings of the U. S. Army. 

i See p. 270. 



OPERATIONS FOR HERNIA. 129 

But the honours of the true hypodermic injection without 
any preliminary incision, I think, after much caieful research 
in the literature of surgery, belong to the late Dr. George 
Heaton of Boston, who* " after eight years of discouraging 
experiment, discovered a process which I call the method of ten- 
dinous irritation" 1 by the injection of a solution of quercus 
alba. Since he performed successful cures by his new method 
as early as 1840, and experimented as he tells us eight years 
previous to this, we are carried back to the year 1832, when he 
first conceived his operation. His first operations were with Dr. 
Jaynes of St. Louis. 24 

In this brief sketch I have endeavoured to be impartial in my 
honour to the various operations, whether they are hypodermic 
or not. I would cast no reflections upon any one, nor at the 
same time endeavour to lessen whatever credit I think may 
justly belong to Heaton for bringing the operation to a full 
fruition and success. Previous operators have relied upon 
suppuration to produce their cures ;~ Heaton tried to avoid 
it. In this is the element of his success, but as will be 
hereafter seen, I soon after taking up the operation, abandoned 
the simple fluid extract of oak bark which Heaton had used, and 
produced by a more stimulating preparation a much more 
abundant effusion of plasto-lymph. That, however, Heaton did 
by his simple injection, effect wonderful cures, can be doubted 
by none. The following is a fair example of his success. 

A soldier by the name of Pitcher was ruptured in the femoral 
region at the battle of Big Bethel, and was discharged in the 
latter part of May from the United States service for physical 
disability caused by said rupture. Dr. Heaton operated upon 
him in June, and after the operation the man again enlisted as 
a soldier in the following September, and served his three years 
without sickness or return of his rupture. You who have been 

1 Heaton on Rupture. See, however, page 3S0 of present work. 

K 



130 EEIINIA. 

with me in the United States service know that a soldier must 
he badly ruptured to be discharged from the army, and I will 
not weary you with more lengthy details. I examined this man 
in March, 1880, and he is still fully cured. 

That Heaton also failed in some of his cases is also true. 
This all must expect, for one of the cardinal principles in sur- 
gery is that wounds will not always heal by the first or best 
intention, and that we never can certainly foretell the results of 
our best endeavours. Upon this point I will speak more at length 
further on. Here I trust I may be pardoned for inserting a 
clinical lecture delivered by Dr. William F. Janney, at the 
Philadelphia Hospital in January, 1880. 

" Gentlemen : — I have the opportunity to-day of exhibiting to 
you a few cases of Inguinal Hernia, and by the consent of one 
of the patients who wished to be cured, I shall perform the 
operation of irritating the abdominal rings according to the 
Heatonian method, which method has been brought before the 
profession by Dr. Joseph H. Warren of Boston, in many articles 
in different medical journals and essays read before medical 
societies. I am not certain that Dr. Heaton deserves the credit 
of being the originator of the operation, but rather inclined to 
believe that to Professor Joseph Pancoast, Emeritus Professor of 
Anatomy, of the Jefferson Medical College, belongs the honour 
of being the first to attempt to cure Hernia by subcutaneous 
injection of an irritant into the inguinal canal. The records of 
the Philadelphia Hospital disclose the fact that Professor Pan- 
coast, in 1836, injected into the inguinal canal and hernial sac 
Lugol's solution of iodine in thirteen cases of Inguinal Hernia, and 
that they were all cured of the hernia, and were retained on the 
farm attached to the hospital, and worked as farm labourers for 
some time. Some worked as long as one year after the opera- 
tion without wearing a truss ; and in no case did the hernia 



OPERATIONS FOR HERNIA. 131 

return. It is with just pride that we claim this operation as a 
Philadelphia operation, and for a more detailed description of 
it I refer you to Pancoast's work on operative surgery. 

" Heaton's claim I think will be recognised as a very slight 
modification of Professor Pancoast's, except that he used a con- 
centrated extract of quercus alba, instead of Lugol's solution of 
iodine. The success of Professor Pancoast's cases did not make 
it a recognised operation by the surgeons of the country, but to 
Dr. Warren, of Boston, is justly due the credit and honour of 
making this operation an assured method of curing Hernia. In 
some cases the Hernia may return, but from my experience in 
this method I am well satisfied that fully seventy-five per cent, 
of all Hernias operated on in this way can be perfectly cured. Dr. 
Warren's position to this operation will be similar to that of the 
late Dr. Atlee to the operation of ovariotomy. These operations 
are two of the grandest achievements of surgery in the nine- 
teenth century, and both by American surgeons. This patient 
that I show you has had right Inguinal Hernia for eighteen 
years, is a sailor by occupation, and is fifty years old. He was 
admitted to this hospital for medical treatment, and was trans- 
ferred to the surgical wards, in order to have his hernia cured. 
I shall now use an instrument for this operation which was 
made for me by Mr. Gemrig, of this city, in April, 1869. It 
consists of a screw syringe so graduated, that when filled and 
ready for use, one quarter turn of the wheel will expel two drops 
of the fluid from the terminal end of the trocar. The trocar is a 
modification of Fitch's ovarian trocar. It consists of a hollow 
tube, that fits on the nipple of the syringe, and is about three 
inches in length, with a small orifice one-twentieth of an inch 
from the distal end ; over this is a sheath or tube with a terminal 
point, similar to the cutting point of a hypodermic needle ; this 
tube or sheath is somewhat shorter than the hollow probe 
attached to the syringe, and is fastened to the hollow probe 



132 HERNIA. 

by a bayonet joint. The patient is now placed on the table, his 
hips slightly raised and the instrument properly armed with a 
concentrated aqueous extract of quercus alba. The cutting 
sheath is unlocked, and the point pushed forward, so as to extend 
about one-fourth of an inch beyond the distal end of the hollow 
probe, thereby closing the orifice for the exit of the irritant. This 
operation, not being a painful one, we will not give the patient 
ether. Taking the instrument in the right hand, with the left 
index finger I invaginate the tissue of the upper part of the 
scrotum, and insert my finger into the external ring. I find that 
the hernia and sac have been reduced with my left index finger 
in the external ring in front of the cord, and pressing upon the 
outer portions of the pillars. I now insert the cutting point 
along my finger, and the pillars of the ring ; then with my right 
index finger and thumb I gently unlock the cutting sheath, and 
push the hollow probe into the inguinal canal, thereby, as you 
observe, retracting the cutting edge along the hollow probe. I 
now have the probe in the inguinal canal, and as it is a per- 
fectly smooth probe it can do no injury to the cord or adjacent 
parts of the canal. I now gently push it up to the internal 
ring, and by one quarter turn of the wheel I deposit two drops 
of the irritant on the internal ringj. and with the end of the 
probe I rub it around the edges of the ring. I also move it to 
another part of the ring and emit two more drops, and gently 
rub it around this part of the ring. I have now applied six 
drops of the irritant to the internal ring. I withdraw the in- 
strument, and apply in the same way the irritant to the external 
ring ; having now applied ten drops to the external ring, I pull 
out the instrument, and apply a pad over the parts, and a 
bandage. You observe that this patient has not complained of 
pain. He will be placed in the ward, and kept in a reclining 
position for the period of two weeks. 

" February 6th — I have now the pleasure of showing you the 



OPERATIONS FOR HERNIA. 133 

patient operated on in January for the cure of hernia. You notice 
that he walks around the amphitheatre without any sign of 
Hernia. We will test the cure, by having him stand upon this 
table and then jumping down ; now by running up and down 
the steps, all of which has no effect upon the hernial rings. I 
think you may consider this man cured, but we will keep him 
under observation for some time yet. 
" May. — No sign of return of Hernia." 

Dr. Janney now says that hereafter in all his operations he 
shall in place of his syringe above described use my new 
instrument (to be described later on), as more effective, less 
dangerous, and in every way far preferable to any yet devised 



CHAPTER VI. 

Author's Operation by Injection. — I. General Remarks. 

II. Author's Modifications of the Injection Method. 

III. Author's Operation. 

From what I have thus far said it will be seen that all of the 
operations, from that of Chauliac to that of Wood, are severe, 
and likely to be attended with great danger of life, if not absolute 
loss of it. It is no wonder then that Bryant and others should 
in their surgeries express great dread of the many so-called 
radical cures, and doubt their expediency and their value. 

No such arguments can be used against the operation that 
I recommend, as no fatal results have ever occurred in any of 
the operations performed by the various surgeons who have 
attempted them. Nor are such results at all likely to occur unless 
the operator unwarrantably interferes with the work of nature 
set up by the injection, unless he makes the injection in the 
most bungling and careless manner, or unless he uses some im- 
proper instrument, such as a scarf or lancet-pointed needle, as 
some few have proposed to use. The use of all such instruments 
has been severely deprecated for reasons which will appear 
later. 

As regards the objection that is often made that all such 
operations which concern the peritoneum are dangerous I can- 
not do better than quote Dr. Davenport, editor of Heaton on- 
Bupture : " Although allusion has been frequently m? de to the 



AUTHOR'S OPERATION BY INJECTION. 135 

necessity of much caution in practising this method for the cure 
of rupture, in order to avoid inflammation, the risk in this 
respect is in reality a very slight one. In the first place, the 
profession have laboured for years under a groundless fear of 
abdominal inflammation, because they have confounded inflamma- 
tion of the parietal wall of the abdomen, which is generally 
easily controlled, and can scarcely be called dangerous, with 
deep-seated peritoneal inflammation of the abdominal contents. 
In the second place, as a matter of fact and experience, no 
inflammation does occur if the operation be performed with 
even a reasonable amount of skill. No surgeon after the ex- 
perience of a few cases will be deterred from trying the 
operation because of apprehension of this danger, unless per- 
chance he wishes blindly to adhere to his preconceived ideas, 
and rest content with the unsatisfactory and evasive practice 
of treating rupture by ordering a truss. Such advice is often 
almost like recommending a man with a broken leg merely to 
get a crutch." By this the reader must not understand too 
much. We do not mean to say that inflammation is not excited 
by our injection, but that peritoneal inflammation is not set up. 
The inflammation that we excite is local in its nature, and rarely 
extends beyond the crest of the ileum. 

Upon this point Professor Wood says : " On reading over the 
opinions of modern writers on Hernia one cannot but be struck 
with the importance they attach to the supposed dangers of 
meddling with the peritoneum and its offsets. Around this 
theory are grouped most of the objections to operative inter- 
ferences. The theory alluded to seems to have been deduced 
from experience of operations performed upon this membrane 
in a state of disease or inflammation, or operations exposing it 
extensively to external influences. Hundreds of operations in- 
volving the healthy peritoneum, both upon Hernise and under 
other circumstances without bad results, have been overlooked 



136 HERNIA. 

or ignored. This prejudice is, I believe, at the bottom of most 
of the objections, as it formerly prevailed against early operation 
in cases of Strangulated Hernia. In the latter cases it seems 
to have generally given way, rendering it more easy to be dealt 
with in the former class. In a general way, inflammation of a 
parietal portion of the peritoneum has been confounded with 
that of the visceral layer or general inflammation of the cavity 
near the important nervous centres. A secluded portion has 
been invested with the attributes of the whole, a logical error 
not uncommon." To illustrate this matter by practical cases 
I insert the following paper upon the toleration of the peritoneum 
to resist injuries. 

This has been a theme of great interest, from very earliest 
times to the present, the older writers often feeling very timid 
in their treatment of any injury or wound, small or great, that 
should occur to the peritonenm, and giving almost, always un- 
favourable prognostications, even in the slightest and most trivial 
injury to this membrane. In many cases, however, the more 
ancient mode of combating inflammation of all kinds, and par- 
ticularly of this membrane, did prove fatal, no matter how 
assiduously the antiphlogistic treatment, internal and external, 
was applied. 

"We are taught, however, by more modern surgery, that by the 
application of water and by the internal use of opium and 
veratram viride, under proper hygienic rules, serious injuries of 
this membrane are not only combated, but brought to a more 
favourable issue. 

This has been illustrated in our civil contest, and other late 
wars. The great tolerance of the membrane has been still 
further illustrated by that honoured son of Kentucky, Dr. 
McDowell, and by Drs. 'Atlee, of Philadelphia, Peaslee, of New 
Hampshire, Spencer Wells, of England, and other ovariotomists, 
as well as by Dr. Heaton, in his numerous injections for the 



AUTHOR'S OPERATION BY INJECTION. 137 

radical cure of Hernia. I have heard from Dr. Heaton's own 
lips that — and so we are led to infer from his published work — 
he frequently punctured the peritoneum, both in the umbilical 
and inguinal region. 

To illustrate this tolerance more fully, I would here relate 
a few instances of the many injuries to this membrane that 
1 have known : — 

In my earliest years Mr. called upon me. He had had 

the misfortune to receive a wound from a large rat-tail file, 
which struck him about three inches above the symphysis 
pubis. It punctured the superficial integuments and the bladder 
near its fundus. 

Here, it is true, we had a favourable portion of the peritoneum 
wounded, as regards subsequent inflammation. 

Although the man had acute cystitis from the injury, still, 
after the wound had discharged pus and urine for some time, 
he made a good recovery, without any peritonitis. 

Another patient, in the year 1856, while in the delirium of 
fever, jumped from an attic window into the door yard, upon a 
stump covered with dry roots. As he fell he was impaled 
through the perineum to the rectum, and the walls of the 
abdomen were pierced in several places, just above the base 
of the bladder and the crest of the ileum, on the right side 
of the linea alba, by those small, dry rootlets, which were 
jagged and rough, and varied in size from a goose quill to half 
an inch in diameter. 

Yet from all this serious injury, suffering as he was at the 
same time with typhoid fever, he made a good and successful 
recovery, suffering, however, for some months, from paralysis 
of the neck of the bladder. 

Still further to illustrate, I will mention Mr. H., a case occur- 
ring in my practice on Christmas Eve, 1857. He was suffering 
from a wounded abdomen, which had been torn from the pubic 



138 HERNIA. 

symphysis to nearly the ensiform cartilage, by a dull jack-knife 
used for the cutting of tobacco. From this wound most of the 
small intestines had escaped to the floor of a room covered with 
coal dust and the debris of a midnight carousal. After ether- 
ising my disembowelled patient, I passed the intestines through 
my hands, bathing off, with warm olive oil, the filth adhering 
to them, and closed the frightful wound by deep sutures and 
adhesive plaster. Over the abdomen I laid a cloth covering 
of cotton wool, and upon this placed a bladder filled with ice, 
which was frequently renewed. I placed the man in bed, ad- 
ministered thirty drops of laudanum and an injection to the 
rectum, and gave, I must confess, a most unfavourable prognosis. 
To my surprise, I found on my first dressing, forty-eight hours 
afterwards, that the wound had healed by the first intention, 
with no peritonitis or other intestinal or abdominal in- 
flammation. 

I may conclude these illustrations by mentioning a very 
remarkable case of rupture of the uterus, while in labour, and 
the escape of the child through the rent into the abdominal 
cavity. This resulted from a contracted pelvis. The woman, 
had gone her full term, and the child, a large one, was extracted 
through the ruptured organ, a wound being made sufficiently 
large to admit the hand and arm of the gentleman with me, 
Dr. Benjamin Cushing, of Boston, so that I could feel his fingers 
and hand at the ensiform cartilage. You may judge of my 
surprise, when, on the following morning, entering the patient's 
room with my autopsy case under my arm, I found, not the fine 
subject for study which I had anticipated (but was happily dis- 
appointed in), but the patient sitting up in bed eating a bowl 
of gruel, and in the most cordial manner saluting me with the 
compliments of the opening day. This case was detailed at the 
time in the Boston Medical and Surgical Journal. 

Suffice it to say that she made a rapid recovery, without 



AUTHOR'S OPERATION BY INJECTION 139 

peritonitis, and in about the usual time as if she never had 
suffered from a ruptured uterus. 

I therefore feel more confident at the present time, after the 
experience I have had, that if in any way, by accident, or in 
injecting, for cure, the hernial rings, whether in umbilical, 
inguinal or femoral, I pierce this membrane, unfavourable results 
will not necessarily occur. As yet I have never had a fatal 
result in any of the cases where I was led to suppose that 
I might have punctured the membrane. I would not, nor would 
I advise any one to puncture the peritoneum, however, if it can 
possibly be avoided. 

I am a firm believer, as you may infer from reading these 
cases, in the application of cold water or ice, either in rubber 
bags or in bladders. I have never seen a case of peritonitis, 
arising from any injury, that was not followed by favourable 
results if these means were used to allay the inflammation, and 
I have yet to see a case requiring the application of poultices 
or hot fomentations to bring about such favourable results. 

These applications of poultices for abdominal inflammations 
involving the bowels, peritoneum, and the uterus, have been, 
I believe, the bane of surgical treatment by ancient physicians, 
and by some physicians of the present day. They are unne- 
cessary, unless there has been an open wound and suppuration, 
and even in these cases a large majority, I think, would be 
better cured by the applications of cold, either dry or moist. 

I can conceive that there may be some exceptions to the 
universal use of these cold applications, and in these cases hot 
stupes of terebinth and opium combined with chloroform might 
be useful, as, for example, in the puerperal diseases of women, 
involving the uterus and its appendages, and attended with great 
tympanitis, and also in the tympanitic condition of enteric and 
gastric fever. Still I think it will be found that in very many 
of these cases the water or ice bags will be of the greatest 



140 HERNIA. 

benefit in a successful treatment of all these inflammatory 
actions. At least I have so found it in my practice, and I more- 
over prefer the ice in a bladder to that in a rubber bag, because 
the tissues of the body take more kindly to an animal tissue 
than to a smooth, clammy, rubber surface. 25 

Every surgeon who has had much to do with operations and 
wounds in the abdominal muscles and integuments, particularly 
in the inguinal and pelvic regions, must be struck with the vast 
amount of sero-plastic lymph poured out from any injury or 
wound of these parts. Even in the application of a blister to 
this portion of the body it will be noticed that we have a far 
greater amount of serum poured out than we do when one 
is placed upon almost any other part of the body. 

In the injections into the hernial rings, for the cure of rupture, 
we take advantage of this, and in some cases we may have 
a full occlusion of the hernial rings, even after we have partially 
divided some of the muscles and ligaments for the release of 
the strangulated intestine, and we obtain a far more favourable 
result than perhaps might be reasonably expected from so severe 
an operation. This takes place from the adventitious tissue 
formed by the serous lymph, and from the cicatricial contraction 
of the wounded muscles ; hence any irritation of these fibres, 
fascia lata, &c, by means of astringent fluids injected upon 
them, will be found to produce a free effusion of this lymph, 
which soon becomes organised, and unites the oblique, internal 
and external, transversalis and transversalis fascia, and so forth, 
fully together. The greater the amount of serous effusion, the 
more sure are we of obtaining this desirable result in the radical 
cure of Hernia. 26 

I have become so familiar with this condition and abundant 
effusion, that I can usually judge whether I shall get an oc- 
clusion and union of the parts of the hernial rings in my 
operation for the cure of rupture, in the course of forty-eight 



AUTHOR'S OPERATION BY INJECTION. 141 

hours. After I have operated, should the effusion be slight, 
I do not anticipate a very satisfactory result, but, on the 
contrary, if it be abundant, I look, and generally not in vain, for 
a most favourable and permanent cure of the Hernia. 



AUTHOR S MODIFICATIONS OF THE INJECTION METHOD. 

Having advanced thus far in our subject, I will, before 
describing the exact modus operandi of my improved operations, 
give a brief account of the way in which I was led to improve 
the instrument and fluid used by Dr. Heaton, with some re- 
marks upon the proper and improper instruments used in the 
operation. 

I began operating for the cure of Hernia soon after the death 
of Dr. Heaton. 

The first patient was Mr. G , aged twenty-three, with double 

direct Inguinal Hernia. I was assisted by Dr. Wm. Emery, of 
Boston, who was his physician at the time of the operation. The 
hernial ring on the right side had become dilated to the extent 
of about one and a quarter inches in diameter by the protrusion 
of the hernial sac and intestine. The hernia on this side had 
existed for over two years, and the tumour formed by the hernial 
protrusion was about the size of a goose-egg. The Hernia upon 
the left side had existed for about a year and a half, was about 
one inch in diameter, while the hernial protrusion was about 
one-half the size of the one on the right side. These herniaa 
being at times very painful, and almost impossible to be retained 
with the ordinary truss during the patient's daily labour, it was 
thought best to perforin the Heatonian operation for hernia, 
which was done in the following manner. With the old in- 
strument of Dr. Heaton, I injected on the right side about 
twenty minims of the fluid extract of quercus alba, which had 
been evaoorated to the consistency of glycerine, and united 



142 HERNIA. 

with an eighth of a grain of morphine ; on the left side about 
fifteen drops. 

In about six hours after the injection the patient began to 
grow feverish and restless ; pulse running to about ninety, tem- 
perature about one hundred. This condition continued for about 
three days, when it began gradually to subside. The urine was 
passed naturally, and a natural passage of the bowels took place 
on the sixth day. There was some swelling and redness over 
the hernial ring, extending up over the abdomen obliquely to 
the crest of the ilium. Dr. Emery attended the case, I seeing 
the patient occasionally. He administered one-eighth of a grain 
of morphine at bed-time to secure rest, and cold water was 
constantly applied over the seat of operation by means of a 
compress. A rapid and successful recovery took place, with 
a perfect cure of the Hernise, and on the twenty-third day of 



Fig. 31. — Heaton's Instrument, with Davenport's Needle. 

July the patient came to my office, when a temporary truss 
was ordered. This he was to wear for several months until we 
should conclude that the tissues had gained sufficient strength 
for him to dispense with it. 

It will be seen from the nature of the case that I here felt 
obliged to use a much larger quantity of the extract of quercus 
alba than is recommended by the late Dr. Heaton in his work 
on the cure of rupture. The instrument, Fig. 31, too, with 
which he performed his operations, I found very much worn 
from constant use in his practice for the last thirty years, and 
very unfit for the purpose for which it was designed, since 
great manipulation was required to exclude the air from the 
barrel of the syringe, because of the loose and worn packing. 
The needle was pierced for the exit of the fluid with two small 



AUTHOR'S OPERATION BY INJECTION. 143 

holes about one-fourth of an inch from its point. In order, 
therefore, to apply the mixture thoroughly to all the circum- 
ference of the ring, internal and external, it was necessary to 
twist the needle around during the injection. The fact is, 
however, that this method of operating caused a very unequal 
distribution of the fluids upon the parts, and much pain and 
needless suffering to the patient. 

I examined also the needle devised by Dr. Davenport, editor 
of Heaton on finp/ure, and found his likewise had but two 
openings, with what I consider a very dangerous point, it being 
lancet-shaped, and liable to pierce the pubic and branches of 
the epigastric arteries, together with other vessels. It thus had 
not even the merits of Dr. Heaton's old needle, 1 which was in 
shape not unlike a bradawl at its point, and which, because 
not very sharp, easily glanced by any vessels it might meet in 
its passage through the integuments. 

Accordingly, in my next case I had a needle made for me and 
pierced with four holes, the first two much nearer the point of 
the needle than in the old instrument. This new needle, I 
found, worked very much better, distributing the fluid more 
equally upon the internal and external ling, together with less 
turning of the needle in the integuments and consequently 
much less pain in the operation. With this needle, as I had 
improved it, I continued to perform several operations with 
much better success than with the needle devised by Dr. 
Heaton. Still when I came to operate for a very large double 
inguinal hernia, one direct and the other oblique, the distance 
through the integuments being greatly increased by adipose 
deposit, I found there was still a great amount of pain which 
I thought unnecessary, produced by the instrument — since, 
being rather blunt at the point, it met with considerable 
resistance in penetrating the tissues. 

1 See Fig. of Heaton's case, p. 370. 



144 



HERNIA. 



When I came to make a second injection, which was necessary 
on the left side of this hernia, since the first injection did not 
succeed in causing the adventitious tissue to be thrown out so as 
fully to close the ring, I found much greater resistance in the in- 
teguments than before, they having become more firmly consoli- 
dated from the effect of the oak bark. The operation thus 
caused considerable pain, although no more than most patients 
could endure without etherisation. 

I next turned my attention to find some means of penetrating 
the tissue into the hernial ring with less pain, and for this purpose 
devised a new instrument, Fig. 32. It consists of a glass barrel 
inclosed in silver, through whose fenestrated openings the fluid 




Fio. 32.— My First instrument, with Revolving Needle. 

can be seen and the presence of air-bubbles detected. The 
number of minims is also plainly indicated on the engraved 
glass barrel, so that we can measure the exact number of drops 
injected in any given operation. It has two semicircular handles 
on the lower end for holding the instrument conveniently and 
firmly during the operation. 

If we next examine the needle or beak, we shall see that it 
is hollow, about one and three-quarter inches long, and that 
throughout its whole length it partakes of a spiral twist, so that 
it will, of necessity, revolve as it enters the tissue, and by such 
revolving penetrate the skin and other integuments much more 
readily than is possible with a straight, bluntly-pointed instru- 
ment. We can readily illustrate this by passing the improved 



AUTHOR'S OPERATION BY INJECTION. 145 

needle through a piece of parchment, and then by performing a 
similar operation with a straight needle pointed like a brad-awl. 
The ease with which the fine needle penetrates, compared with 
the resistance which the other meets, proves conclusively that 
the former instrument must do its work with much less pain 
than the latter. The secret of this is that with the straight 
needle we get constant friction and bearing on the entire length 
of the needle during the whole operation, whereas with the 
spiral form of the needle the friction and pressure are on but 
a small portion of the body of the instrument at any one time, 
and are thus reduced to the minimum. 

Then, again, it is to be observed that the needle, instead of 
being round, is of a flat, oval shape, and makes a wound of the 
same form. In this way there is a more ready coaptation of the 
wounded tissue than would be possible with a round puncture. 
The needle is pierced with ten openings upon its sides, which 
causes a more free and equal distribution of the fluid ejected. 
The difference between this and the hypodermic needle, which 
I shall speak of later on, is that, instead of the direct terminal 
uses of the fluid, we have it spread at right angles to the needle, 
and therefore gain a better distribution upon the hernial rings, 
internal and external, at the same time avoiding the applica- 
tion of the fluid to the peritoneum which we wish to irritate 
as little as possible. 

With the hypodermic syringe, however, the principal flow of 
the fluid would be upon the peritoneum, and not upon the parts 
intended to receive it, thus making the operation, in view of the 
small amount of fluid recommended, of limited and doubtful 
success. If we examine the attachment of this needle to the 
barrel of the syringe, Ave shall see that the needle is held in 
place by a coupling and collar, which allows it to revolve while 
on its passage through the integuments. 

The head of the needle within this collar is rounded something 



146 HERNIA. 

like the smaller end of an egg and on its bearings is in contact 
with a diamond or other hard stone which is concaved to fit 
accurately the convexity of the needle. In this way we avoid 
almost entirely the friction which would, if metal met metal, 
prevent the free revolution of the needle ; and at the same time 
we render the joint sufficiently tight to prevent all leakage of 
the fluid as it passes from the chamber of the instrument into 
the needle. 

Some improper instruments having been used in this opera- 
tion I have to make the following general and important 
criticisms upon all sharp-pointed needles, like that on Fitch's 
trocar which has been used for the purpose, or like that devised 
by Dr. Janney of Philadelphia, previously described. 

I do not wish to be considered an opposer of any other 
gentleman ; on the contrary, nothing pleases me so much as to 
have others do this operation successfully. When, however, 
they attempt to do it, I do hope that they will select a proper and 
safe instrument to work with. If any one can devise a better 
instrument than has been devised, I, for one, should be happy 
to have him do it, and shall be happy to use it. But I hope 
they will be sure that it is safe, and that it gives honour to the 
good name of the operation, before they make it public as an 
improvement on both Dr. Heaton's instrument and my own, 
which are already in successful use. Therefore, as the only 
living man whom Dr. Heaton ever personally taught the opera- 
tion as it was performed by him, I protest, in the name of 
humanity, against the use of any sharp, or angular-pointed 
needle in the operation, and I emphatically warn the profession 
to expect many unfavourable and even dangerous results from 
the use of such instruments ; results which probably might have 
been a successful cure had proper instruments been used. 

Lest the profession should consider me over cautious in this 
matter I will refer to an incident during a recent visit I made 



AUTHOR'S OPERATION BY INJECTION. Ml 

to New York. Dr. Post desired me to go to the Presbyterian 
Hospital to see a patient he had operated upon for Hernia, but 
in whom he had not ventured to make the injection from the 
surface, for fear of injuring the arteries and other vessels. He 
had therefore first cut down upon the rings with the scalpel, 
freely, and then injected. He was in dread of these sharp- 
pointed instruments, but thought my new-pointed instrument 
avoided the difficulty. If this skilful and veteran surgeon, 
famous for his successful operations, dreaded and did not dare 
use a sharp-pointed instrument, how much more should the 
mere tyro in surgery avoid their use ? It is impossible to be too 
cautious in this region so rich in surgical anatomy. 

In addition to this it should be stated that in my method of 
performing the operation, instead of applying the fluid to the 
internal hernial ring first, as in Dr. Heaton's operation, I reverse 
the process and do this last ; for as soon as my needle has pene- 
trated the tissues, I immediately begin to eject the fluid upon 
the external ring and its surrounding parts, and so continue 
until I reach the internal ring. After sufficiently bathing the 
latter with the fluid I withdraw the instrument, still continuing 
to eject. 1 

In performing in this manner we complete the operation in 
one half the time employed by Dr. Heaton, and, comparatively 
speaking, with an absence of pain. At the same time we en- 
tirely avoid the sweeping motion of the needle described in Dr. 
Heaton's treatise, a process which I consider very much endan- 
gers the wounding or irritation of the muscular fibres and blood- 
vessels composing the rings. 

Furthermore, the tissues being less likely to be serrated or 
irritated with my needle than with his, there is much less 
tendency to the formation of abscesses from such irritation 
than in the old operation. 

I find, too, that the extract of oak bark employed by Dr. 

i See pp. 170, 383. L 2 



148 HERNIA. 

Heaton is not well held in solution, being liable to much sed- 
iment, the powder forming granulations which do not readily 
pass through the syringe, and which, if ejected, form a consider- 
able irritation, and therefore a great tendency to abscesses. A 
better and safer formula is to evaporate the fluid extract of oak 
to about the consistency of glycerine, add sufficient absolute 
alcohol to reduce it about one half, and then add about one half 
a dram of sulphuric ether to the half ounce of fluid. To this 
mixture I also add about two grains of sulphate of morphia, 
thus making one of the most perfect injecting fluids that I have 
thus far been able by numerous experiments to devise, combin- 
ing the astringent effect of Dr. Heaton's extract of quercus alba, 
together with that of the German method of using alcohol alone, 
and producing the most favorable results in this operation of 
injecting the hernial rings for the radical cure. 27 

The use of an ordinary hypodermic syringe would be, I con- 
sider, an operation attended with much danger, not only from 
the liability of penetrating a portion of the pubic and epigastric 
arteries, but also because the instrument would be a poor and 
feeble one for thorough and successful operations on Hernia, 
since it is well known that the needle has to act in some degree 
as a staff and guide in slightly lifting up, as it were, the integ- 
uments, which are often thick and supplemented by excessive 
adipose tissue. 

I hardly need call the attention of any surgeon of prominence 
who keeps well up in the anatomy of these parts to the great 
danger of wounding the epigastric and pubic arteries, and other 
blood-vessels and nerves, by a sharp lancet or angular-pointed 
instrument. The cautious surgeon well knows that his patient 
might easily receive a dangerous wound here and bleed to 
death, perhaps, before it be discovered and secured. Hence, 
after what is known and has been said on the subject, a hypo- 
dermic syringe, or any thin and sharp-pointed instrument, will 



---.-'■- • ■■" 



3 ^&fe?->- 




s^ 



: ^^^00^' 



PLATE C. 

INGUINAL AND CRURAL CANAL. 

(Seen Outwardly.) 

From BLANDIN. 

Explanation of the Plate. 

A. Portion of the thigh. — B. Penis. — C. The testicles. — D. Hair of the 
pubis. — E, E. Portion of the anterior abdominal enclosure (costo-iliac region). 
■ — F. Anterior and superior iliac spine. — G. Eight muscle in its sheath. — 
H. Pyramidal muscle eqnally in its sheath. — I. Aponeurosis of the great 
oblique. — J. Hook which lifts up a portion of the aponeurosis of the great 
oblique, detached over the crural arcade, where it forms the anterior enclosure 
of the inguinal canal. — K, K. Crural arcade. — L. Inguinal ring crossed by 
the testicular cordon, and sending from its circumference a fibrous expansion 
upon the cordon. — M. Fibrous expansion detached from the circumference of 
the inguinal ring. — N. Internal or superior pilaster of the ring. — 0. Ex- 
ternal or inferior pilaster of the ring. — P. Place where the crural arcade con- 
tinues with all the thickness of the fascia lata aponeurosis. — Q. Place where 
the crural arcade adhered only to the superficial leaf of the fascia lata aponeurosis 
leaf, which here has been detached and overturned outside. — R. Sinus, open in 
the upper part, which the crural arcade forms in continuing backwards and above, 
with the fascia transversalis sinus which constitutes the inguinal canal. — SS. 
Fascia transversalis aponeurosis, which forms the posterior enclosure of the in- 
guinal passage, in a place where of the three muscles of the abdomen only the 
external oblique one is found. — T. Place where the fascia transversalis aponeu- 
rosis rises from the external edge of the right muscle. — VVV. Inferior edge con- 
founded and horizontally directed from the small oblique and transversal muscle. 
— V, V, V, V. Muscular handles of the cremastereous muscle formed by an emana- 
tion upon the cordon of the inferior edge of the small oblique and transversal 
muscles. — X. Testicular cordon, in the middle of which are seen the flexuosities 
of the testicular veins. — Y. Ileo-scrotal nerve of the lumber plexus. — Z, Z, Z. 
The adipous skin and tissue of the abdominal enclosure, turned down. — &. Fascia 
superficialis aponeurosis. — a. Cordon knotted upon the fascia superficialis aponeu- 
rosis, detached from the abdominal enclosure, and overturned upon the thigh and 
hip. _ b, b,b. Tegumentary vessels of the abdomen. — c. Genital external super- 
ficial vessels. — d, d. Anterior enclosure of the crural canal, cut and overturned 
from inside to outside in order to show the crural canal. — e. Large lymphatic 
ganglion, placed before the crural canal. — f,f. Openings of the anterior enclosure 
of the crural canal, which are crossed by lymphatic vessels. — g. External enclo- 
sure of the crural canal, formed by the deep leaf of the lata fascia, supported upon 
the psoas and iliac muscles. — h. Opening made to the external enclosure of the 
crural canal, in order to show the crural nerve placed immediately outside of it, 
in the sheath of the psoas. — i. Femoral artery, placed outside of the vein of the 
same name. — j. Femoral vein placed within the artery. — i. Internal sapheneous 
vein. — m. Inferior opening of the crural canal, crossed by the internal saphe- 
neous vein. — n. Fibrous falciform bunch, placed at the confluence of the saphe- 
neous and femoral veins. 



AUTHOR'S OPERATION BY INJECTION. 149 

appear extremely dangerous to most successful surgeons. I 
should suppose there was hardly a single maker of surgical 
instruments who would be a party to the manufacture of any 
such dangerous instruments, and much less that there was any 
surgeon who would attempt to use such foul implements on any 
human being. 

Indeed, one of the many reasons why Dr. Heaton preferred 
a needle like a bradawl, with a round and somewhat blunted 
point, was that it would easily and safely glide off the coats of 
the vessels. In my instrument I further guarded against 
danger by a round and blunt-pointed needle, which would revolve 
in penetrating the tissues. In this way there is still less danger 
of wounds or unnecessary irritation than in Dr. Heaton's method 
of sweeping the needle around, so as to distribute the fluid 
equally upon all the parts. With my instrument the fluid is 
simply and completely distributed around the rings and canal 
during the act of entering and withdrawing the instrument, and 
there is no possible danger of injury to the parts during the 
operation. 

There has been some misunderstanding too about the manner 
in which the injection should be given. From an ordinary 
hypodermic syringe the fluid will be injected straight forward, 
while Dr. Heaton strove to force his fluid in a spray at right- 
angles to the needle. This is an essential point in the operatioD, 
since it is the hernial rings and not the hernial sac that we 
desire to irritate. 28 

Although it is high time that this operation should be better 
understood, still a thorough comprehension will neither lessen 
our great esteem for the more formal surgical operation for 
Strangulated Hernia, as now performed by all modern surgeons, 
nor will it be less essential for all practical surgeons thoroughly 
to understand this latter operation. 

So long, however, as thousands upon thousands are ruptured 



150 HERNIA. 

with reducible Hernia?, which have heretofore required all the 
ingenuity of mechanical art to support and retain within the 
abdominal cavity by bands of iron and steel, elastic fabrics, hone 
and ivory thereby endangering life hy their liability to become 
strangulated, and often abruptly terminating existence hy the 
strangulated intestines becoming sphacelated and gangrenous, 
before relief can be ohtained by the surgeon's knife, or the more 
gentle operation of taxis ; so long as this is the case, the dis- 
covery of a permanent cure seems a most wonderful blessing for 
mankind. 

Should I ever he disappointed in the success of this operation 
for the relief and cure of rupture, I should be the first to 
acknowledge it. 

Allow me to add, I know of no operation in the annals of 
surgery that requires a more delicate touch, and finer manipula- 
tion in all its details, or a steadier and firmer hand in the 
operator, not even excepting the fine and graceful operation 
of cataract on the eye. What operation demands more care 
than passing a sharp-pointed instrument through the living 
tissue into the hernial ring, among numerous tissues, vessels. 
nerves, and surrounded by the peritoneal membrane ? I know 
of no operation more simple and painless, or that brings forth 
such rich results in relief, comfort, and almost certain cure in 
nearly every case when performed by a skilful operator, than 
this one for the cure of rupture. But when awkwardly and 
indifferently performed by one deficient in the anatomical and 
surgical knowledge proper for the undertaking of the operation, 
I know of no operation so fraught with danger to human life, 
and one so barren in results, and therefore disappointing to both 
physician and patient. 

In regard to the duration of the after treatment, my experi- 
ence has been, and it was the experience of Dr. Heaton, that the 
effusion of plasto-lymph around the parts is not sufficiently 



AUTHOR'S OPERATION BY INJECTION. 151 

organised in five or ten days after the operation into adherent 
and fibrous tissue, to bear any strain at all upon them. They 
would at once separate and give way. Dr. Heaton caused his 
cases to remain at rest at least ten or twelve days. That we 
know from his experience, and I can say the same has been the 
case in my experience. 

Finally, I wish to add a word of caution and advice to those 
who may have to do with this operation. Should the patient 
get up too soon after being operated upon, or make any undue 
exercise or exertions before the parts have acquired sufficient 
union, consolidation, and firmness, they will very readily be- 
come separated, and of course let the Hernia escape again ; or, 
should there be union in the parts sufficient even to retain the 
Hernia within the abdominal rings, yet a secondary swelling may 
again appear in the track of the first swelling and inflammation 
which usuall} 7 " attends the primary operat-on. 

This secondary swelling, more particularly if it follows after 
we have made two or three injections, which are often found 
necessary fully to close the hernial rings, will appear in any form 
of Inguinal Hernia very prominent over the seat of the injected 
parts, not unlike an inverted common saucer in size and appear- 
ance, extending along the oblique to the crest of the ilium, and 
will assume a dark maroon colour. If we now examine it, it will 
appear to the touch as though fluid or pus were present. 

This is not, however, the case ; it is only a slight effusion and 
exudation of plasmatic serum, together with some mingling with 
the discoloration produced by the extract of oak injected. If 
now we cut freely down, exposing these parts to view, we see 
that the tannin in the mixture injected has united with the ex- 
udation, causing the appearance of the tannate of albumen. This 
will show itself by the striated, shroudy, and granulated sub- 
stance resembling dry blood when moistened again. If we 
should now constantly apply compresses of cold water and 



152 HERNIA. 

allow the patient to remain in bed, on his back, this redness and 
swelling will generally, in the course of two weeks, entirely 
disappear. 

Such cases, when fully over all inflammatory attacks, will be 
found to be stronger in the hernial rings than those which had 
only the primary inflammation following the injection, because 
this secondary inflammation more fully unites the parts inflamed 
by thickening an additional deposit of organised lymph over the 
seat of the operation. But we should not be misled by this 
inflammation and proceed at once to open this large swelling, as 
we thereby very greatly endanger the result of the primary 
operation for the relief of the rupture, and put the patient's life 
in great and needless danger. 

We should patiently wait, and after a sufficient time, it will, 
if it be an abscess, converge, in the course of ten or twelve days, 
to about the size of a Seckel pear, and something like it in shape 
and appearance. Then, and not until then, we should proceed 
to open the swelling, and even then we should first be able to 
feel the fluctuation of the pus through the thinned walls of the 
abscess. And if still in doubt, from our diagnosis, whether it 
be an abscess or not, we should, before opening, pass into the 
swelling one of the finest needles of the aspirator. 

Cold water is the best dressing, and all through the treatment, 
from the very beginning to the perfect recovery to the normal 
condition of the inflamed parts, neither lotions nor ointments 
are required. 

Now, sometimes when we discharge a patient after this opera- 
tion, he is commanded to wear a truss or bandage, not to lift or 
jump either from the cars or any other height, and to be very 
careful about any violent exercise whatever; all of which he 
promises to do. But the person so dismissed, cured to all 
appearances, will possibly feel so mighty and proud in his re- 
covery that, although he may for a time follow the instructions, 



AUTHOR'S OPERATION BY INJECTION. 153 

he will some fine morning cough, perhaps, and force the abdo- 
minal parts down in order to see how strong he is in this region ; 
or taking a peculiar delight now m examining what previous to 
the operation was so repulsive, he will try to lift a heavy weight, 
pull a hand-cart if he takes a notion, or see how high he can 
reach. 

From these self examinations he may feel satisfied that he is 
perfectly cured, and yet, in the very acts in the time of his 
unusual exertions, he has started and opened the adhesions 
formed in the hernial rin<^, and in the end his state will be 
nearly as bad as before ; for upon the least yielding of these new 
adhesions the peritoneum and intestines will insinuate them- 
selves through the most minute opening, and act like a wedge 
in forcing the parts asunder. 

Had he been more cautious in following explicit directions, 
and waited a year or two before making violent exertions, he 
would never have had to bear a return of his rupture. Should 
a return of his Hernia unfortunately take place, another opera- 
tion and injection will generally effect even a firmer closing of 
the rings than the first operation did, because of a decidedly 
greater condensation and stronger cohesion of the parts treated. 
But I am assured that he never again, in his joy, will experiment 
to see how perfectly he is cured. 

Sometimes, after the hernial rings are closed, as Dr. Heaton 
says in his work, and as I myself have seen, portions of the 
hernial sac, particularly in cases of long standing, are fastened 
down in the folds of the rings and surrounding parts, after the 
operation for cure has been successfully applied, and this may 
lead the patient — nay, even the physician — to think that the 
hernia has not been in reality cured. If, however, as I have 
already said, the rupture remains closed for a year or so, the 
cure may be looked upon as certainly a permanent one. 

Suppose, however, that this hernial sac can be passed readily 



154 HERNIA. 

through the hernial rings, then a very slight amount of the 
injection will close the parts efficiently, leaving the patient 
much strengthened by the operation. 

I wish to call attention again and especially to the fact, that 
although this operation is generally successful upon its first 
performance, yet it has sometimes to be repeated several times 
before we get a full and strong occlusion of the rings, particularly 
in hernias of large and long standing. If, after we have once 
operated and have succeeded in partly closing the opening, we 
find we have not done it so as fully to effect a permanent cure, 
we must, after the lapse of eight or ten days, repeat the ope- 
ration, and continue so to do until we have entirely closed the 
parts beyond danger of opening. Thus, by perseverance, and 
thus only, we shall in the end be delighted and rewarded by the 
perfect cure of almost every case we undertake. 

Even after the patient has returned to his usual occupations, 
and has seemed, both to himself and the operator, cured, upon 
the slightest indication of the return of his troubles he should 
at once present himself for examination, and, if necessary, an- 
other operation. Indeed, not only in this operation, but in all 
others in surgery that may be presented to me for treatment, I 
could not positively, and under all circumstancess, warrant a 
permanent cure any mere than if I performed ovariotomy or 
the amputation of a limb, for it is well known that from some 
unforeseen circumstances in the operation, or in the conduct 
of the patient submitted, success may not always and with 
certainty follow a good and legitimate attempt at relief. 

author's operation. 

With all due deference to the many and honoured operators 
for the cure of Hernia, I now give my improved operation, with 
a description of my new instrument and injecting fluid. While 



AUTHOR'S OPERATION BY INJECTION. 155 

I' make no claim to originality beyond whatever originality is 
required to perfect and bring to a scientific development what 
before, in a crude and imperfect form had worked many good 
results, I am encouraged to present whatever I have done 
because of the very general interest shown by the profession in 
my own country and in other countries, in what I have already 
given them in the medical journals. My method of performing 
and presenting the operation would seem to be more acceptable 
to the better and greater part of the profession than previous 
operations, if I can judge by the letters of congratulation I 
receive from distinguished surgeons of this and other countries, 
fully approving the operation as safer and freer from all follow- 
ing complications than any operation heretofore proposed. Thus 
far I have not had a single fatal case, and the worst case I have 
had was an old congenital hernia cited in the report of interesting 
cases (see p. 192, operations 3, 4, 5) read before the Suffolk 
District Medical Society. 

The operation is here given with some slight increase of 
matter, being nearly as read before the British Medical Asso- 
ciation at Cambridge, 12th August, 1880; and presented before 
the Academie de Medecine, 31st August, 1880. 

It gives me great pleasure to have the honour of addressing 
you at this, the annual meeting of your venerable Associa- 
tion, on the treatment of Hernia by a new method, by means 
of an instrument and injecting fluid of my own devising. 

As many of you are aware, I have written considerably on 
this subject, and by means of the various medical journals, the 
so-called radical cure of rupture has been circulated through 
the medical profession, and caused no little interest. But I do 
not like the term " radical " as applied to this or any other 
operation, for it is not euphonious, and is distasteful to the true 
surgeon, sounding as it does of charlatanism. It sounds un- 
professional to all preconceived ideas of medical and surgical 



156 HERNIA. 

science, and in my humble opinion it should not be so much as 
named among us in speaking of this or any other operation. 
Let us in speaking of this operation call it by its true name, an 
operation for Hernia by injecting the hernial rings. 

I am aware that some of the most honoured men that have 
brightened the pages of surgical literature or taught in our 
Universities have applied the term radical to the operation for 
Hernia, but notwithstanding this I would take exception to the 
time-honoured precedent, and in accordance with the present 
spirit of medical and surgical art, call this operation by its 
true name, trusting that we shall be quite as successful in 
curing and relieving our patients as we should under the irre- 
gular name of radical cure. In all my future papers and work 
upon Hernia I will join hands with the profession and erase the 
objectionable word, and will speak of treating and curing rup- 
tures by this method as we do of any operation devised for 
the cure of any affection. 

I would here take the liberty of expressing at this time my 
most sincere thanks to the distinguished profession of London, 
New York, and Boston, as well as to the profession generally 
in my own country and Europe, for their kind criticisms and 
consideration of me in presenting my imperfect papers on 
Hernia, which are given while engaged with many cares incident 
to an active professional life. 

In presenting this paper, I wish to say here that in giving my 
new instruments and method to the profession I do not wish to 
^detract any credit from the late Dr. George Heaton, of Boston, 
nor underestimate his valuable work on rupture, nor the great 
labor and pains of his late co-editor, the refined and scholarly 
Dr. Davenport. 

On the contrary, I look up to Dr. Heaton, not only as my 
former master and instructor in this operation, but as one from 
whom I gained all my inspiration for my present and future 



AUTHOR'S OPERATION BY INJECTION. 



157 



efforts in developing and demonstrating this, as yet, as I feel, 
imperfect operation on Hernia. To Dr. George Heaton will 
always belong the honour of first injecting the hernial rings 
with fluid extract of oak bark, Quercus alba, for the radical cure 
of rupture, if he was not the first to inject hypodermically. 

I am, as will be seen, working over the field of operation of 
Hernia, trying to perfect and improve any deficiencies w^hich I 
find in the treatment by injections, and it will be my greatest 
desire to be candid and truthful in all that I do and present to 
my medical brethren; and may I not hope with their kind 
assistance to accomplish much in this operation, which does not 
as yet seem to be fully understood by the profession or 
appreciated as it properly should be ? ao 

The following is a short description of new syringe and 
instrument for injecting the hernial rings in the cure of 
Hernia. 29 




FlQ. 38. 



The instrument which I show you consists of a barrel, A, 
holding about sixty minims. This barrel is of glass, accurately 
fitted within a cylinder of silver, which is fenestrated with two 
openings to present a view of the barrel and its contents. The 
barrel is graduated, each degree indicating ten minims. The 
piston B works by a spring c, very tightly, within this tube, so 
as to exclude all air possible. The lower end D of the piston 
is slightly concaved. At the bottom of the interior of the glass 
barrel there is a ring e, one-eighth of an inch in thickness, 
made of soft rubber, for an air chamber, with a hole in its 
centre for the exit of the fluid. 



158 HERNIA. 

On the lower exterior end of the barrel will be seen a 
convenient semi-circular handle, with the concave side rough- 
ened to give a firm hold for the finger and thumb of the 
operator. 

A valve is situated just below the bottom of the barrel and 
rubber chamber, and is opened and shut by pressure on the 
lever c. We thus have perfect management, both of the 
amount of the fluid to be injected and of the time when it 
shall be injected. Below this valve is a diamond, or other hard 
stone, concaved to fit exactly the convex head of the needle 
which plays upon it. 

The needles are flattish, oval in shape, and are twisted 
throughout their entire length. They are of three sizes. No. 1 
is one and a quarter inch in length, size two and a half 
American scale ; No. 2 is one and three-eighths in length, size 
two and three-quarters American scale ; No. 3 is one and a 
half inch in length, and size three. It should be remembered 
that, from their peculiar form and twist, they make an incision 
only about one-half the size of round needles which measure 
the same on the scale. The twist of the needles also varies. 
No. 1 is twisted to revolve once in penetrating one-fourth of an 
inch, No. 2 once in penetrating one-half an inch, and No. 3 
once in penetrating three-quarters of an inch. I use No. 1 
in operations on umbilical Hernia and other Hernise where the 
tissues are thin. It is therefore small, and has a quick twist 
because it is necessary that the needle in penetrating should 
make a full revolution, so as to distribute the fluid on the parts 
to be irritated by the injection. No. 2 is for use in operating 
on the majority of small and recent Hernise. No. 3 is for use 
on large and long-standing ruptures, where the needle must 
traverse tissue generally much thicker than in the other cases 
mentioned, and often surrounded by adipose deposit. The 
needle has a round shank, playing through a collar, which is 



AUTHOR'S OPERATION BY INJECTION. 159 

attached by a screw thread to the neck of the barrel. This 
needle does not bore in passing, but turns round in a spiral 
manner as it advances, and the same can be said of all the other 
instruments to be hereafter described, except the aspirating needle, 
which is twisted in through the tissues by slight pressure and 
revolving it at the same time. 1 

I have said that there was a rubber cushion at the bottom 
of the glass tube. This cushion remedies the defect common to 
hypodermic as well as all other syringes, for it forms an air 
chamber which arrests the passage out of any air that may be 
in the barrel, and there is always more or less which would 
be injected with the fluid. It also acts very effectually in 
stopping the farther action of the piston after all the fluid has 
been injected. 

The method of using the instrument is as follows. With the 
valve closed, the needle is inserted in the fluid to be used. The 
valve is now opened by slight pressure upon the lever. The 
pressure being continued, the piston can be retracted, and the 
barrel will be consequently filled with the fluid. The valve 
is then allowed to close, and the instrument is charged for use. 

Having selected the most suitable point over the rings to be 
injected, we now thrust the needle slowly and gently, but at the 
same time firmly, through the integuments. During this act 
the needle revolves because of its twisted form. As soon as it 
has passed through the integuments, pressure is made upon the 
spring, which opens the valve, and allows the fluid in the barrel 
to flow as slowly and in such quantities as the operator may in 
any given case think necessary. The quantity used can, of 
course, always be known by the engraved scale on the barrel. 

1 See First Edition. 



1G0 



HERNIA. 



ANATOMY OF FEMORAL A1SD INGUINAL HEENIA. 1 

The real and essential anatomy of the parts where our seat ol 
o Deration lies/ we find to be the following: 




Fig. 3i. 

Shows the anatomical relation and coverings of Oblique Hernia, b, transversalis 
fascia ; c, peritoneum ; a, muscles, internal oblique transversalis, and ex- 
ternal oblique ; d, external integuments. These illustrations were drawn 
under Mr. Cooper's directions from my friend Mr. John Wood's work on 
Rupture, who very kindly permitted me to make use of them for this work. 



The inguinal or spermatic canal begins at the internal ab- 
dominal ring, its length being about one and a half inches. It 

1 See p. 51. 



AUTHOR'S OPERATION BY INJECTION. 1G1 

serves for passage of the spermatic cord in the male and the 
round ligament with its vessels in the female. Its boundaries 
are : 

In front — Tendon of external oblique muscle, lower border 
of internal oblique and a small portion of the cremaster muscle. 

Behind. — Fascia trans versalis, conjoined tendon of internal 
oblique and transversalis muscles, and the triangular fascia. 

Above. — Arched border of transversalis muscle. 

Below. — Poupart's ligament. 

This inguinal canal is of great surgical importance on account 
of its being the channel through which inguinal Hernia escapes 
from the abdomen. Inguinal Hernise are of two kinds, oblique 
and direct. The former enters the inguinal canal through the 
internal abdominal ring, passing obliquely along the canal and 
through the external ring to descend into the scrotum. Direct 
inguinal Hernia escapes from the abdomen at Hesselbach's 
triangle and passes through the external ring. 

Hesselbach's triangle is situated at the lower part of the 
abdominal wall on either side. Its boundaries are : 

2ftitfema%.— Epigastric artery. 

Internally. — Outer margin of rectus. 

Below. — Poupart's ligament. 

The following are the coverings of the two varieties of 
inguinal Hernia, commencing at the surface : 

Oblique. Direct. 

1. Skin. 1. Skin. 

2. Superficial fascia. 2. Superficial fascia. 

3. Intel-columnar fascia. 3. Intercolumnar fascia. 

4. Cremaster muscles. 4. Conjoined tendon of internal 

5. Fascia transversalis. oblique and transversalis muscles. 

6. Sub-serous cellular tissue. 5. Fascia transversalis. 

7. Peritoneum. 6. Sub-serous cellular tissue. 

7. Peritoneum. 



M 



162 



HEKNIA. 



FEMORAL HERNIA. 



The crural or femoral canal is a funnel-shaped interval which 
exists within the femoral sheath between its inner walls and 
the femoral vein, and is the space into which the sac of femoral 
hernia is protruded. It is limited above by the crural or femoral 




Fig. 35. — Femoral Hernia. 
For description of plate, see Fig. 52. 

ring and is lost below by the adhesion of the sheath to the coats 
of the vessels. In the normal state, the canal is occupied by 
loose cellular tissue and numerous lymphatic vessels, which per- 
forate the cribriform fascia covering the saphenous opening in the 

1 See p. 66. 



AUTHOR'S OPERATION BY INJECTION. 163 

fascia lata and the walls of the sheath, to reach a lymphatic gland 
situated at the crural ring. This gland is retained in its position 
by a thin layer of sub-serous cellular tissue — septum crurale — 
which together with the peritoneum separates the canal from the 
abdominal cavity. The crural ring is the point where femoral 
Hernia leaves the abdomen, and is the most frequent seat of 
strangulation. Its boundaries are : — 

In front — Poupart's ligament. 

Behind. — Ileo-pectineal line, and body of pubic bone. 

Externally. — Femoral vein. 

Internally. — The sharp margin of Gimbernat's ligament. 

The coverings of femoral Hernia commencing at the surface 



are 



1. Skin. 

2. Superficial fascia. 

3. Cribriform fascia. 

4. Femoral sheath or fascia propria. 

5. Septum crurale or sub-serous cellular tissue. 

6. Peritoneum. 



THE POSITION FOR OPERATION IN THE CURE OF HERNIA BY 
SUBCUTANEOUS INJECTIONS. 

L have often done this operation on a table made of white 
wood, for the sake of lightness, about six feet long and one foot 
wide. It is supported by three pairs of legs, which at the foot 
are two feet four inches high, and at the head two feet high, 
while the central ones are nineteen inches high. These legs 
diverge from the middle line of table to give the greatest 
possible stability. 

There are four leaves attached to the top of the table, two on 
either side ; that is, each leaf is about three feet long and six 
inches wide. The two leaves at the head of the table are spread 
open for the patient to lie upon, while the two at the foot are 
allowed to hang at the sides of the table. On these latter 

M 2 



164 HERNIA. 

leaves is placed a foot-rest for the patient, so that his limbs 
may be in a proper position for a convenient operation. These 
leaves, as well as the legs, are hinged to fold up, and are 
properly braced to be held in position during the operation. 

The table has in its centre, and about three feet from the 
lower end, an oval opening six inches in diameter, around 
which the surface has been bevelled to fit accurately the patient's 
sacrum and hips. 

The table being first covered with sheets or blankets, or, if 
necessary, a rubber cloth, the patient is laid upon it with the 
head upon the lower end of the table. In this position the 
spine partakes of the curvature of the table top, the pelvis and 
hips being elevated. 

If desired, a small pillow can be laid under the head so as not 
to elevate the shoulders unduly. The patient is now in position 
for the operation in umbilical, inguinal, and femoral Hernia ; a 
position clearly the most favourable for the entire relaxation of 
the spinal, abdominal, and limb muscles. The Hernise may 
now be returned within the abdominal cavity, where they will 
remain on account of the position of the patient, and can be at 
once operated upon. 

This table can also be used in the treatment of uterine diseases 
and for operations on the anus, by placing a staff at the foot of 
the highest end of the inclined top on which to suspend a 
fountain syringe, bucket, or other vessel. The patient will be 
found to lie on this table in the very best possible position for 
the treatment of such cases on account of the concavity of 
the table from head to foot, and the circular orifice will allow 
all overflow to escape, thus keeping the patient clean and dry. 

I now prefer and use the Goodwin invalid bedstead in my 
operations in place of this table, as I find it better adapted 
and much more convenient while operating, and the patient is 
not obliged to be moved afterwards till able to be up again, and 



AUTHOR'S OPERATION BY INJECTION. 165 

the desired elevation can be obtained, as the foot and head can 
be lowered or raised to any height and firmly remain so long as 
we wish by the means of a canvas bottom that is pierced with a 
hole, so that the bed-pan can be used without any trouble for all 
the calls of nature. 



OPERATION FOR INGUINAL HERNIA 

The patient is first placed upon this table, or, if the table 
be not at hand, upon a bed, in which case the hips should be 
elevated by a pillow, whilst the head and shoulders should 
be allowed to fall somewhat lower in order to produce a slight 
curvature of the spine and a relaxation of the abdominal 
muscles. 

If a bed is used, the legs of the patient should now be drawn 
up, but if the table is used, this same position is gained by the 
foot rest below the surface of the table. 

The patient being thus in a relaxed yet firm position, we seek 
the Hernia to be operated upon, and, after reducing the protruded 
intestinal sac and omentum by taxis, we pass the left middle 
finger up the spermatic canal until we come to the inguinal ring. 
The end of this middle finger, being slightly raised as above 
mentioned, is felt by the forefinger, which also helps us to indi- 
cate the exact point, and is a guide to insert the point of the 
instrument. Having ascertained that the ring is well open and 
free from attachments or adhesions to the returned sac, we begin 
to insert the needle at the lower portion of the ring, where we 
feel its edges through the abdominal parietes. 1 

The needle should always enter this lower portion of the ring, 
as in passing obliquely upwards and backwards it is less likely 
to wound either column of the internal ring. Great care should 

» All the sac that can be put back free from adhesions must be returned 
If it is firmly bound down the injecting fluids should be freely distributed 
around it as thoroughly as possible. 



166 



HERNIA. 



be taken in inserting it through the integuments and superficial 
fascia, so as not to wound the external pillar, but to enter the 




Fig. 36. — The three most common forms of Hernia, in the order of their occurrence in the mole, 
are (1) Oblique Inguinal ; (2) Direct Inguinal ; (3) Femoral. 1 



canal at once. The needle then should never be passed in 
a perpendicular direction,, as there is thus danger of wouud- 

1 The artist has drawn the instrument too nearly horizontal, so that it 
appears as if it were entering the right groin. The instrument should lie 
across the thumb of the left hand between the first and second joints, 
making an angle of about forty degrees when the needle first enters. 
After passing the superficial integuments the instrument should be de- 
pressed so that the needle may pass freely into the rings along the superior 
surface of the spermatic cord, taking care not to wound the cord. 



AUTHOR'S OPERATION BY INJECTION. 167 

ing the spermatic cord, but it should receive the necessary 
obliquity as soon as we feel that it has passed through the in- 
teguments. We can diagnose the position of the needle when 
first entering, by passing the left fore or little finger up with the 
invaginated scrotum upon it. When we have passed the needle 
through the integuments, we begin to open the valve and slowly 
push the needle in the direction already indicated. As the needle 
is thus inserted, it revolves and injects the fluid in sufficient 
quantities to cover well the external and internal rings. 1 The 
needle is now slowly withdrawn, still injecting fluid in its back- 
ward motion. As soon as the needle is withdrawn, pressure is 
made with the end of the fingers over the wound and rings for 
five or ten minutes, until the smarting and throbbing pain 
subsides. 

Now a pad about three by four inches and three-quarters in 
thickness is made by folding a linen napkin once or more. This 
pad should be immersed in cold water and applied, gentle pres- 
sure being at the same time constantly exerted until the bandage, 
which should be double and three or four inches wide, is passed 
round the body and firmly secured by pinning. In double 
Hernia this bandage should be kept from slipping upward by 
two perineal bands beginning at the crests of the ileum and 
pinned near the symphisis pubis in front. 80 

The patient is now placed in bed with his legs side by side 
and should remain upon his back in this position for from 
twenty-four to forty-eight hours. He should not be allowed to 
rise in voiding urine or attending to other calls of nature 
but the bed-pan should be used for such natural calls. 

1 In most cases ten to twenty-five drops will be sufficient. It will be 
remembered by those present at my operation, August 19 tli, 1880, at Guy's 
Hospital, where the ring was. very large, as demonstrated by Mr. Bryant 
and Mr. Smith of the Seamen's Hospital, that I was obliged to use thirty 
drops. 



168 HERNIA. 

OPERATION FOR FEMORAL HERNIA. 

Same position of the patient as above. Having ascertained 
by diagnosis whether the Hernia be femoral or inguinal, that is, 
having found the relation the Hernia bears to Poupart's liga- 
ment (femoral Hernias lying below this ligament and inguinal 
Herniae above), and having selected the position of the saphenous 
opening to which we are easily guided, if the femoral Hernia 
has emerged from the femoral canal, the operation is performed 
in a manner similar to that in inguinal Hernia. 

This saphenous opening we can usually locate by pressure in 
the thigh below Poupart's ligament and about three-quarters of 




Tio. 37. — Femoral Hernia as usually seen In female. 

an inch to the inner side of the femoral artpry. Over it usually 
lies a lymphatic gland, which is much enlarged if a truss has 
been worn. 

In most cases the sharp edges of the falciform process or 
fascia lata may be found thickened and hypertrophied from 
friction. This results from the action of the truss upon the 
Hernia, and forms our landmark, for its curve is peculiar and 
not readily mistakable in making our definition. For similar 
operation see H&aton on Rupture. 

The Hernia having now been reduced and the forefinger 
pressed against the outer edge of the falciform process, the 



AUTHOR'S OPERATION BY INJECTION. 



169 



needle of the instrument is inserted into the canal just above 
the saphenous vein and on the inner side of the femoral vein 
which is held to one side by the finger, care being taken not to 
forget the femoral vein that often lies posterior to the hernial 
membrane. The needle thus enters the femoral canal external 
to the hernial membrane. 

The irritation applied to the crural ring should be slight, as 
femoral Hernia will not require so much of an irritant as an 
inguinal one of nearly the same size. The pad and bandage are 
applied similarly to those in inguinal Hernia, only run the 
Spica bandage as seen in Fig. 38. 

r 




Fio. 88.— Sptca Bandage. 



Of all Hernioe, femoral are the most difficult to cure by this 
operation, especially in females, as they require the utmost skill 
and care on the part of the operator, because of the extreme 
length of the ligaments which make up the crural ring, and 
because of the immediate relation of the femoral veins and 
arteries, and because in large and long standing Herniaa the sac 
is often ramified by branches of largo veins and arteries, 
together with lymphatics. 



170 HERNIA. 



OPERATION FOR UMBILICAL HERNIA. 

From the ease of diagnosis this will not require any lengthy 
description. The patient is placed upon his back as in femoral 
Hernia, except that the feet may be slightly elevated. The finest 
needle which revolves once in going one-half of an inch, is 
selected and passed to the centre. As soon as it has penetrated 
the integuments, we deliver the injection with some force upon 
the edges of the ring by throwing the valve wide open. 

Care should be taken in this operation not to puncture the 
peritoneum. Where the integuments are very thin and the 
Hernia small, as in children, the hernial rings should be seized 
with a pair of dressing forceps and elevated while the needle is 
passing through them. In extreme and old Hernise of this 
kind, two or even three points may be selected for injecting the 
irritant. This is necessary in cases of extreme size, in order 
that the liquid may bathe the edges of this enlarged umbilical 
ling. The bandage and pressure is the same as in the other 
cases mentioned. 

In addition to these usual injections into the hernial rings, I 
have found when the opening in the rings has been very large, 
the following plan of reinforcing the ordinary effects of our 
operation to be of great value. While withdrawing my needle 
after the primary injection, I allow sufficient fluid to escape into 
the superficial parts to create a more or less permanent swelling 
over the rings. This has a tendency to form a large tumefaction 
over the seat of operation, and acts not only as an additional 
support, but also as a compress just where we most need and 
desire pressure. This contracted thickening of the tissues will 
remain in this state for months, and adds much to the success 
of the operation. 

One might think at first, from this swelling, that we were 
dealing with an abscess produced by our injection, but this is 



AUTHOR'S OPERATION BY INJECTION. 171 

not so. On the other hand, we often do get small superficial 
abscesses similar to those following the hypodermic injection of 
morphine or ergot ; but these are of short duration, seldom larger 
than a pea, and after ten to fifteen days may be pricked. They 
will exude their contents — usually a mixture of bloody serum 
mingled with our injecting fluid — and in a short time will 
readily heal. 

This modification of our usual operation is especially effective 
when the patient is very spare and thin over and in the vicinity 
of the hernial protrusion, when we are dealing with either 
inouinal or femoral Hern se. From this it will be evident that 
in all cases of umbilical Hernise it will always be best to inject 
the superficial tissues, because the integumentary coverings are 
so thin and require so much the more the additional cicatricial 
thickening. 

If upon the day following the operation of injection we find 
there has not resulted a sufficient flow of lymph, we can readily 
excite a greater flow by pressing the ends of the fingers into the 
external ring, pushing all the external integuments down upon 
the internal ring, and when our fingers are in this position, by 
rubbing and twisting the integuments between them with more 
or less force. This rubbing should never be repeated after the 
first day succeeding the operation ; and in consequence of its 
necessity, we should warn our patient that he must remain at 
rest a day or two longer than if the rubbing had not been made. 

Heaton, to supplement his injection, was in the habit of 
serrating the columns of the internal ring with the point of his 
needle. We should, however, remember that if this manoeuvre 
be carried to too great an extent, the result might be that 
inflammation would set in rather than the effusion of lymph, 
that we might seriously injure the peritoneum, or that we might 
cut some important vessel from which a severe, if not fatal 
haemorrhage might take place. It is not a procedure that I 



172 HERNIA. 

should recommend any one to adopt, as with my more stimu- 
lating injecting fluid, and the after operation of rubbing, I can 
with more safety and surety obtain far better results. 

At the risk of repetition I will, at this point, institute a 
comparison between the effects produced by the old fluid of 
Heaton and the new mixture of my own. The application 
of a mustard paste to the surface of the skin will excite a great 
amount of irritation, and what might have been called, by older 
writers, a dry and local inflammation. If in place of the mus- 
tard we apply a blistering plaster of cantharides, we shall get a 
greater amount of lymph effusion with far less soreness, tender- 
ness, and inflammation of the surrounding tissues. From this 
I intend the inference to he drawn that mere soreness and 
tenderness of the rings is no criterion that the operation of 
injecting the hernial rings has been successful in occluding 
the hernial opening. On the other hand, the success of the 
operation depends entirely upon the effusion of lymph sufficient 
to produce new tissue in the rings. Of the amount of this 
effusion we can judge by the soft and fluctuating appearance of 
the swelling over • the seat of our operation, feeling like fluid 
beneath the folds of a thick rubber bag. 

AFTER TREATMENT. 

From six to eight hours after the injection, an increase of 
temperature, a slight increase of pulse and a feverish condition 
showing a slight constitutional disturbance will set in and con- 
tinue usually from three to four days, when it will be found 
gradually to subside. The patient should have a light liquid 
diet, and, unless otherwise indicated, should have cold water 
constantly applied by means of a compress, from beginning to 
end. Morphine or some other anodyne can be administered to 
secure quiet. The bowels should not be moved, if possible, 
until the sixth or seventh day, and then by some gentle cath- 



AUTHOR'S OPERATION BY INJECTION. 173 

artic. Fluid as drink can be had ad libitum in the way of cold 
water, but no stimulants of any kind except under the utmost 
urgency, and on ho account is tobacco to be used. 

This treatment should be continued for at least a week 
or ten days, the patient lying in bed and as much as possible 
upon his back. The first four days he should remain constantly 
upon the back, as any other position might injure the process of 
adhesion of the rings caused by the irritant. 

This is an operation which, if it should not be successful, has 
put the patient to but little pain, inconvenience, or danger ; and 
should we not fully succeed, we have not left our patient worse 
than we found him, as there is always a partial if not a full 
occlusion of the rings : — so if we do not fully close them, we 
have somewhat benefited the patient. This cannot be said of 
many other operations performed for the relief of Hernia. 

It now, perhaps, would not be out of place to consider the 
various kinds of Hernia which would promise the most favour- 
able results from this operation in our next chapter. See Sec. IT. 

In performing this operation it is not desirable to use ether, 
as it is apt to excite vomiting, and I only resort to it with the 
very timid and sensitive. It will be found more necessary to 
etherise in children and women than in men, to overcome their 
fear rather than from any pain they would experience in the 
operation. 

Chloral hydrate may be given a few hours before the operation 
with almost as good results as those obtained from ether, pro- 
ducing sleep and freedom from pain and fear. 

Great care also should be taken not to allow the patient to 
stand upon his feet too soon, as from past experience I am 
convinced that very few cases which have needed a second 
operation after they have in the opinion of the physician and 
the patient himself, completely healed, would have required a 
repetition of the injection, had they been more prudent and 



174 HERNIA. 

been content to remain quiet a little longer. Do not be too 
anxious then to see the results of the operation, but let nature 
take her time in occluding the rings. 

Moreover, when we allow the patient to stand upon his 
feet for the first time, we should support the injected parts 
with the tips of the fingers and on no condition remove this 
support while he is standing. He should not be allowed to 
cough, bear down or make any undue exertions for two or tlnee 
months, at least. 

A bandage or truss should now be worn for from three 
months to a year or even longer if the patient follows any 
occupation where great violence or powerful exertion is liable 
to occur. After this if the rings remain occluded and firm 
he may dispense with the truss or bandage. 

ON OBSERVING CASES. 

From a careful watch kept over the after history of cases 
we have operated upon, we shall probably from every case learn 
something new and valuable to us which will be of perhaps 
incalculable benefit to us in some future operation. I have yet 
to see two Herniae precisely alike in every particular. Although 
the kinds of Herniae usually met are few, the variations upon 
these few kinds are indefinite in number and appearance. 

Examine each case carefully, study it in its minutest detail, 
mark well all the surrounding and attending circumstances, 
whether the Herniae be large or small, painful or not, congenital 
or accidental, age of patient at the time the Hernias first 
appeared and at the time of operation, history of the Hernia, 
habits and occupation of the patient and whether there is any 
hereditary disposition to Hernia in the family. 

Carefully noting all these points, we are enabled to treat the 
patient and the Hernia more intelligently and carefully than if 
we knew nothing more than the mere fact that a Hernia exists 
upon which we are requested to operate. 



CHAPTER VII. 

General Remarks. — I. Selection of Patients. II Kinds of 
Hernia best treated. III. Percentage of Cures. IV. 
Causes of Failure. V. Record of Interesting Cases. 

i. — selection of patients. 

A CAREFUL discrimination between the different conditions of 
the Hernial and of the patients to be operated upon should always 
be most scrupulously made if we would have success attend our 
efforts for relief and cure. The operation I present is no more 
adapted indiscriminately to all suffering from Hernia than is 
any other surgical operation for the relief of any other bodily 
affliction. No surgeon in capital operations would think of 
disregarding the physical condition and attendant circumstances 
of a patient submitting himself for treatment. Why should 
this disregard be so common in the treatment of Hernia ? I 
am convinced that the vast majority of Hernia cases are treated 
in just this careless way, and that in this method of treatment 
lies the secret of the poor success of many of the operations. 

This subject has never to my knowledge been stated, dis- 
cussed or emphasised in any essay or work on Hernia, and I 
am more and more surprised every day to think that such an 
important and indispensable element of the operation should 
be allowed to pass unnoticed by the many writers upon the 
subject. 



176 HERNIA. 

Although Dr. Heatou said nothing of this in his work, I am 
convinced from my personal friendship and intimacy with him 
that he always made a careful selection of his cases, and that 
in this was one secret of his success. When speaking of his 
invariable success he was in the habit of giving me a peculiar 
wise and knowing look of the eye, and he would say that he 
cured all, or about all, that he would operate on. At that time 
T did not attach much importance to this expression, but now 
that I have been operating myself I think I see the meaning. 
The selection of his cases was the great and only secret that 
he withheld from the profession. He often ridiculed the idea 
of the indiscriminate application of the method of injection to 
any and all cases of rupture, saying that the general health 
of the patient had much to do with the success of the 
operation. 

I am sorry that in his work on rupture he still preferred to 
keep this important portion of his secret to himself. From what I 
have already said I think the reader can safely judge that I am 
perfectly free and open in the whole operation, and that I am 
desirous that the operation shall stand and be criticised only upon 
its true and tried merits. I would under no consideration lead 
a single operator astray in the operation whether by being too 
self-confident or by unfairly and with prejudice and conceal- 
ment stating my candid views upon the subject. What I seek 
is that mystery may be removed from the operation. 

When this operation is attempted upon persons in poor and 
indifferent health or of great delicacy, enfeebled by age or a 
broken constitution, upon those who have lived lives of in- 
temperance and debauchery or who are suffering from syphilis 
or scrofulous affections, upon those living in crowded and 
unhealthy places as in the filth and poverty of a great city, 
upon those in hospitals, or public institutions as almshouses, 
jails, places of detention, or prisons, or upon poorly nourished 



GENERAL REMARKS. 177 

and anaemic persons and upon dispensary patients, the prognosis 
will be very unfavourable and the chances of success very small 
and uncertain. 

On the other hand, we may expect to get the best and most 
successful results with the least trouble and vexation from the 
operation when it is performed upon persons in a high state of 
health, muscular strength and vigour, upon those who live in the 
country, or who are in the habit of being in the open air much 
of their time. I find persons who are in the following out-of- 
door occupations to be the most favourable to receive the 
operation for Hernia, and I have endeavoured to arrange the 
list in a careful order placing the occupations that promise the 
greatest health in their successive order : Farmers, country 
gentlemen and their domestics, teamsters, lumbermen, sportsmen, 
soldiers, sailors and marines, masons, carpenters, civil engineers, 
men employed on railways, and professional men. 

II. — KINDS OF HERNIA BEST TREATED. 

Having now spoken of those upon whom this operation is 
likely to succeed, it here, perhaps, would not be out of place to 
consider the various kinds of Hernia which would promise the 
most favourable results from this operation. 

In accidental or congenital Hernia in persons between the 
ages of four and twenty years, the most favourable results may 
be expected. Unless the Hernia be large and of long standing, 
the injection need not be very stimulating. The youngest 
child I have operated upon was four years of age. This was a 
very delicate operation for a large umbilical Hernia, which was 
not easily controlled by mechanical means, owing to its size and 
extensive protrusion. The operation resulted in a cure. I 
would not advise the operation for femoral or inguinal Hernia 
unless the patient was at least five or six years of age, pre- 
ferably ten or twelve. In the cases of these little patients a 

N 



178 HERNIA. 

properly fitting truss, which may itself effect cure, should 
usually be tried first, unless the child be very nervous or the 
parts so irritable as to render the truss or other support 
intolerable. 

After the age of twenty-one the cure is more difficult. 
Satisfactory results are only to be obtained by the use of a 
more stimulatiug injection. More than one injection is often 
required. The older the patient and the larger the Hernia, 
the greater the difficulties become, though enormously lar^e 
Hernise, such as, to all appearance, would preclude reasonable 
hope of cure in accordance with our previous ideas, may now 
be relieved or cured. Almost certainly if we do not succeed in 
closing the hernial rings, we may cause a certain amount of 
contraction and a corresponding degree of relief, if not a cure ; 
at least the patient will be benefited rather than injured by the 
operation. Some patients even say that they would gladly 
submit to the operation once in a few months rather than suffer 
the hernial protrusion. The opinion of certain critics that the 
operation, if unsuccessful, would do harm by leaving the edges 
of the rings fringed and jagged and sensitive, may be safely left 
to the honest opinions of such gentlemen as may give the 
matter their careful consideration. The absence of cutting and 
irritation of the surrounding parts with the knife, or sharp 
instrument, is opposed to this criticism. The parts, after the 
operation, naturally become infiltrated, from the internal to the 
external rings, with plastic lymph. Should this give way, which 
may possibly occur, the previously agglutinated parts, we may 
presume, w 7 ould remain as smooth and free as before the 
operation. 

I have never seen a case once fully cured by this operation in 
which the relief has not been permanent. Even partial con- 
traction of the rings certainly favours more or less retention 
of the Hernia within the abdominal cavity. I have never 



GENERAL REMARKS. 179 

observed a case in which reabsorption of the effused lymph 
had taken place, although subsequent rupture of the new 
plastic formation may occur. But in my experience, at least, 
it has not occurred to its former extent. I now refer to cases 
operated upon by Dr. Heaton, in which his plan, his instrument, 
and his mixture were employed. In these cases I believe 
the cure would have been perfect had the treatment been 
repeated once or twice. 

In my personal experience I have yet to see a case of relapse, 
after a cure has been perfected, nor do I believe such a case 
will occur except in extreme old and congenital Hernia, or 
as the result of undue straining due to convulsions, or to some 
other cause. Inguinal Hernia, direct or oblique, is most 
easily treated by this operation, and a favourable result is 
most nearly certain. Umbilical Hernia, in respect of results, 
stands next to the inguinal. The most uncertain variety, 
and the most dangerous to treat, is the femoral, which will 
be found to require much less fluid in proportion to its size 
than any other variety. I have expressed the opinion that 
ten drops injected into the femoral, are equal in irritative 
power to twenty drops in inguinal or umbilical Hernia. Old 
ruptures with thickened sac and adhesions are more difficult 
to manage, owing to their attachments. In such cases, after 
reducing as much as possible, do not inject the sac all around, 
but throw the greater portion of the fluid upon the superior part 
of the adhering sac, so as to get abundant effusion to form 
attachments on the upper surface of the protruding sac. By this 
means we shall more probably secure both occlusion and con- 
traction of the rings. This is because the superior parts of the 
hernial rings generally give way first, on account of contraction 
of the abdominal muscles. In such cases more or less bulging of 
the parts after the operation will generally be present, an appear- 
ance which may wrongly be considered by the inexperienced an 

N 2 



180 HERNIA. 

evidence of failure. Close examination, however, will show 
that the protruding intestines are held securely in place. This 
bulging may be expected in all cases of old or long-standing 
ruptuie, because the muscles and integuments which have been 
so long distended by the protruding Hernia, naturally remain 
pendent. 

I desire to lay additional stress upon the fact that this latter 
class of Hernise should receive the most stimulating fluid to 
produce an effusion that would be at all effective in forming 
adequate adhesions. Bepeated injection will also be required 
more frequently. The cases most difficult to effect a cure upon 
are those of old congenital Hernias in patients over forty. In 
these cases the pressure of the abdominal visceroe has been so 
strong at the superior portion of the internal and external rings 
that the two rings have practically been fused, so to speak, into 
one, and the surrounding muscular fibres have been changed into 
an unyielding condensed tissue. Upon this structure no fluid 
injection whatever is to be relied upon as capable of producing 
much exudation of plasma. The adhesions, therefore, would be 
very delicate, and it is questionable whether such adhesions and 
contractions would form in these cases, even though the patient 
were kept quiet for a considerable time. I am now engaged in 
the study of these doubtful cases, and have devised a procedure 
which seems to have promise of success. Should it succeed, I 
shall present it to the profession at a future time. 1 

When the Hernia is in a state of inflammation from whatever 
cause, whether from the galling of a truss, or from an irritation 
produced by the reduction of a strangulation, or by the more 
or less forcible attempts to reduce an irreducible Hernia by 
dilating the rings after the manner of M. Vidal, no operative 
procedure by injection should be attempted. We should wait 
until the inflammation has subsided. 

If the rupture is of long standing, is very large, and 

i See p. 383. 



GENERAL REMARKS. 181 

accompanied with a greatly thickened sac of omentum, it would 
not be advisable to return the omentum with the intestines, 
particularly if it has formed adhesions and attachments around 
the rings and other parts. By attempting to return it we should 
almost inevitably stretch and enlarge the hernial rings that are 
about to endeavour to contract by our injection. Therefore it 
would be far better to excise the protruded portion of it, and to 
apply a carbolised ligature just above the point of excision. A dull 
knife, or the herniotomy saw of my device (see Fig. 56, page 239, 
for description and cut) will be found of very great advantage 
in dividing this omentum. After it has been sufficiently reduced 
in size to be returned into the abdominal cavity with the in- 
testines, we may paint the parts with the fluid described under 
the treatment of strangulated Hernia, and proceed to dress and 
bandage as I have directed in reducible Hernia (see p. 169 and 
Fig. 38). See also p. 167. 

In brief and to recapitulate: 

Congenital Hernial of all kinds in children from five to twenty 
years of age are very favourable, and almost effectually cured 
by this operation. No child under four years of age should 
undergo this operation except in -extreme cases. 

Herniae, caused by accidents, when of short duration, even 
when quite large, are very effectually and generally cured by 
this operation. 

Herniae that have been caused by over-exertion such as 
convulsions, child-bearing, and the like, and which have existed 
over twenty years, can also be generally cured, requiring, how- 
ever, more than one injection usually. The longer their duration 
and extent the more liable are we to be obliged to perform 
repeated injections in order to fully close the ring. 

Congenital Herniae of large size and long standing are difficult 
to successfully relieve and cure, unless we make several injec- 
tions, although I operated last summer (1879) on a double 



182 HERNIA. 

congenital Hernia (inguinal), one ring being two inches in 
diameter and the other one and a half inches. The one was 
fully closed with the primary operation, and the larger opening 
was closed by two injections. At the time of operating, the 
patient told me his Hernia had existed for eighteen years, but 
after he was cured he informed me that his mother said that 
he was born ruptured, he being at this time upwards of forty 
years old. 

I speak of this case here to show what this operation is 
capable of doing. This patient was formerly not able to retain 
the Hernia on one side, it being so large, and the rings were 
so thin and the integuments so dilated that it would bul^e out 
over the support which he was obliged to wear constantly. Yet 
the bowels of this patient are, to-day, retained within the 
abdomen, and he is very comfortable, although as a precautionary 
measure he is to wear for a year or more, as may be necessary, 
a very delicate and soft French spring truss of Tiemarm's 
importation or manufacture. From such results as these I have 
astonished myself, perhaps, more than anyone else, as previous 
to my experiments and trials of the operation I could not believe 
that it was possible to produce such favourable results. 

III. — PERCENTAGE OP CURES. 1 

It will be seen from what I have said that Dr. Heaton 
professed hardly ever to have had a failure. Although he was re- 
markably successful yet I know he did have failures, especially 
in the last year of his life, because I have already met such 
cases, have operated on some of them, and shall operate on 
others in the near future. Dr. Janney, of Philadelphia, who 
next to me has now operated on the greatest number of patients 
by this subcutaneous method, thinks that he may fairly and 
without exaggeration claim 75 per cent, of cures. How many 
out of any given number of persons can receive a permanent 

1 See pp. 384 and 391. 



GENERAL REMARKS. 183 

cure by the method of operation as I do it, I am not at present 
able to say with exactness. I can however make an estimate 
based upon the cases I have thus far treated, and should judge 
that fully 80 — 85 per cent, of all I have operated on have been 
successfully cured. I base this high estimation upon the more 
stimulating fluid that I use, and the method of using it, as well 
as in the careful after-treatment. If such success shall continue 
to attend my efforts, and the efforts of those who may take up 
the operation, I shall certainly think that I have not in vain 
called the attention of the profession to the value of the cure 
by subcutaneous injection. Time and trial is the only means 
of settling this matter satisfactorily and conclusively. In all 
cases remember never to warrant a cure. Such confidence is 
beyond the bounds of all professional propriety. 



IV. — CAUSES OF FAILURE. 

Many who undertake to perform this operation will perhaps 
meet with failures upon their first attempts, and thus be ready 
to condemn the operation as useless, and think it overrated by 
the author and by those who may have been equally successful. 
They will imagine that we are too sanguine in our expectations, 
and referring to all the operations hitherto attempted from 
Celsus to Wood will class them and this in the same category 
as dangerous, seriously liable to failure, and outside the doors 
of legitimate surgery. They will not stop to consider that their 
ill success may be from fault of the operator, and not of the 
operation, but will jump at once to their hasty conclusion. 

I have already spoken of the cause of failure as a result of 
performing the operation upon subjects not fitted to receive the 
full benefits of the injection. To show how little the operators 
upon Hernia have considered this matter I will mention the 
following instance. 



184 HERNIA. 

While I was recently present at St. Albans, Vermont, to read 
a paper before the Vermont State Medical Society, a Professor 
in the Vermont University of Medicine, and also in one of the 
New York Schools of Medicine, told me that he should operate 
on every one that would let him. He said he had already 
operated once on a child without good results, and wished to 
know why I would not operate upon a ch'ld that was among 
other patients there presented to me to illustrate my method 
of cure. I told him the case was a very improper one. The 
child was only about three years of age, and the Hernia 
being an oblique inguinal, the spermatic and inguinal 
canal was not large enough to admit the middle finger freely 
into it. Besides all this, the child was nervous and uncon- 
trollable, so that it would have been impossible to keep it still 
without opiates long enough to effect a consolidation of the 
lymph effused, even if we could have succeeded in producing 
such an effusion, which in a majority of these young cases is 
very doubtful. 

Now this professor is one of the best surgeons in New York 
city, very highly esteemed by me, and has performed many fine 
and difficult surgical operations that are a credit to the pro- 
fession he so ably adorns. This very fact that gentlemen of 
such distinction do not comprehend this operation, leads me more 
to the conclusion that the profession at large do not comprehend 
it, to say the least, any more fully. 

Another cause of failure is that we may not have used a 
fluid for the injection that was sufficiently stimulating to 
agglutinise the parts around the rings, or if we use a proper 
fluid we may use too little to produce the desired effect. If on 
the contrary we use too much, we shall run into the danger of 
producing abscesses and suppuration, which is fatal to tissue 
formation from lymph. Sufficient compress may not have been 
made over the parts operated upon, the patient's bowels may 



GENERAL REMARKS. 185 

have been moved too soon, absolute rest may not have been 
enforced for the first four -or five days succeeding the operation, 
so that the primary stage of tissue formation shall not be in the 
least disturbed, the patient may have been made to cough or 
perform some muscular exertion too soon after the operation, or, 
as I have before insisted, an improper instrument may have 
been employed. From all of these causes, it may happen that 
the injection will not be followed by success. 

To illustrate how inconsiderate some may be in the after 
treatment, I mention the following incident selected from the 
many that could be cited. The gentleman under whose pro- 
fessional care I left the patient that I operated upon in St. 
Albans, June 15th, 18S0, wrote me, July 3rd, as follows : — 

"Dear Sir, — The man J. B. on whom you operated is 

apparently well. T kept him on his back eight days ; then put 

on the truss. There has been no appearance of the Hernia thus 

far. I had him cough the other day with bearing down without 

bringing down the gut. 

"Yours truly, 

"G.D." 

Such heedlessness is provoking, and contrary to all my advice. 
It is a wonder that such experimental coughing and bearing 
down does not often bring down the Hernia again in spite of all 
we have done for its retention. 

One more cause of failure must be mentioned even at the risk 
of seeming to speak of a point so simple as to be almost self- 
evident. After all that has been said and written upon Hernia, 
many do not select, or seem to know, the precise locality or the 
proper part where to introduce the injection. Some have even 
thought that we could cure a Femoral Hernia by injecting above 
Poupart's ligament. The merest tyro knows better. Others 
have asked whether the injection is to be thrown into the sac or 



186 HERNIA. 

into the spermatic cord. I am sorry to say that both these 
methods have been tried and success foolishly awaited. 

V. — RECORD OF INTERESTING CASES. 

In order to emphasise what can be done by this operation of 
injection, and to present a record of some very interesting cases, 
I insert, with a few changes to adapt it to book form, a paper 
read by me before the Otsego County Medical Society of New 
York, and before the Suffolk District Medical Society of Boston, 
Mass : — 

When we consider the terrible distress this complaint of 
Hernia entails upon humanity, is it any wonder that a vast army 
of our fellow beings, rather than submit to the knife and the 
painful operations now performed for the cure of Hernia, seek 
relief at the hands of irregular and often itinerant practitioners, 
who by flaming advertisements and artful promises offer sure and 
painless cures, only to entrap, and so to say, devour their innocent 
victims, like the wolf in the fable ? In view of such impostors 
and impositions, is it not high time that every son — I was about 
to add every daughter — of Esculapius should heartily aid every 
honest endeavour you or I or any member of the regular 
profession may make to develop, in an open and legitimate 
manner, an operation that has been many times performed with 
success ? Nay, more, are we not in duty bound to the cause of 
science to endorse and encourage all such efforts, at least so far 
as they rest upon a true surgical principle and possess the merit 
of an honourable attempt to advance the medical and surgical 
art? 

Many have been the attempts in the past to operate for the 
cure of Hernia by injection, and among the operators we find 
the noted names of Velpeau, Pancoast, J. Mason Warren, and 
others. While one discovered this important principle, and 
another that, none except Heaton ventured to inject hypoder- 



GENERAL REMARKS. 187 

mically without first cutting down upon the parts, and none 
were so successful as to warrant us in saying that they had 
really discovered a radical and lasting cure, except Dr. Heaton. 
But because Dr. J. Mason Warren successfully injected 
sulphuric ether in one case (see Observations on Surgery, page 
166), I am not bound to use only sulphuric ether in my injec- 
tions ; because Schwalbe, of Germany, injects alcohol, and 
Heaton oak bark, I am not bound to use either alone, if I can 
find a better formula. We all must reason for ourselves, and I 
feel confident that by combining ether, alcohol, oak bark, and 
morphia, in my injecting mixture, I occlude the rings with less 
disturbance of the constitution and of the heart's action, than 
where a single fluid is used alone. I wish to say just here, that 
at the time when I made up my formula I knew nothing of the 
use of sulphuric ether by Dr. Warren, or of alcohol by Dr. 
Schwalbe, in the cure of Hernia. (Although it is a strange 
coincidence, the idea was as truly original with me as it had 
been with them.) I recall one of my cases where the pulsation, 
which just before the time of operation was eighty per minute, 
fell after the operation about ten beats, and continued to fall, 
until in an hour it was sixty-five. While, then, this mixture 
exerts a sedative influence on the arterial system, its stimulating 
properties cause a rapid and localised effusion of lymph where 
it is desired for the organisation of new tissue. 

In developing the operation, as I have said, I have not been 
necessarily the apostle or disciple of any one, nor have I felt 
myself bound by the teachings or examples of any one, except 
so far as I recognised that true principles and worthy precepts 
had been given. I present it to you simply on its merits, and 
ask only that you fairly investigate its principle and results 
before passing judgment on it. 

I think I know somewhat of the conservativeness of the better 
part of our profession, and while I am, upon proper grounds, the 



188 HERNIA. 

most conservative of conservatives, I do not believe it fair or just 
to be unreasonably prejudiced. Judging from the history of 
medicine and surgery, I feel very confident that when this opera- 
tion is examined in its details and thoroughly understood, it will 
be accepted as one of the most legitimate operations for cure of 
Hernia. I do this operation as we perform all surgical operations, 
as an experiment (for we should always remember that every 
operation in surgery is on this principle). 

I cannot with regard to truth and modesty, boldly assert such 
favourable terminations in all of my operations as we are led to 
infer by Dr. Heat on, in his work upon Hernia and in his reply 
to the committee sent him by the American Medical Association. 
Although he boasted so freely, yet you and the medical gentlemen 
in every city in the country know that he did not cure all upon 
whom he operated. There are some half dozen whom he attempted 
to cure, who are to present themselves to me for operation ; one 
in particular, to whom Dr. Heaton said: "You see that sun 
shine ? well, just as sure as that sun shines I can and will cure 

you." 

I also find much in his book that is vague and unreliable, and 
might, if implicitly followed, lead one astray in the operation. I 
have the best of reasons for saying that had he lived he would, 
in a future edition, have corrected many statements, particularly 
in regard to the inflammation set up. This I know from going 
over the whole ground with him personally. Indeed, he greatly 
regretted that he had ever given the operation to the profession, 
from the fear that all would not fully comprehend his meaning, 
and that some one would use a dangerous-pointed instrument 
and bring discredit upon his pet operation, and, possibly, seriously 
injure or even kill a patient. 

He would again and again refer to these hypodermic needles, 
spear- and lancet-shaped instruments, in terms far from com- 
mendatory, saying, " They will yet cut some artery so minute 



GENERAL REMARKS. T89 

that it will escape their notice at the time, the patient will bleed 
to death, and then they will condemn me and my operation." 

I have thought that perhaps the best way for me to show you 
the merits of this operation for the cure of Hernia is to tell 
you of its success in my experience. I will therefore detail 
a few of my cases very carefully. 1 

Operations Nos. 1, 2. — On July 10th, 1879, I operated upon 
Mr. G., aged twenty-three, for double inguinal Hernia direct, on 
both sides. The openings in the rings were one and a quarter 
inches and one inch, respectively I injected about twenty 
minims into the larger rupture, which was on the right side, and 
fifteen minims into the smaller one, on the left side. After 
going through the ordinary course of a slight feverish condition, 
with an increase of temperature for three or four days, the case 
made the usual recovery, by perfect occlusion of the hernial 
rin<*s and retention of the intestines within the abdominal 
cavity. 

The patient appeared at the expiration of ten or twelve days 
as if he had never been ruptured, and no one would have known 
i hat he had ever been, unless by previous knowledge of the fact. 
The cure was simply perfect, without even the bulging of the in- 
teguments that we often see when by this operation a cure has 
been effected in large Hernias. 

The patient being a labourer, dusting and washing cars, I 
thought it best for him to remove the bandnqe which we had 
applied while he was undergoing the treatment, and wear a truss. 
I therefore ordered a double, hard rubber truss, thinking that this 
would give him the best security and freedom from accidents. 

For this truss I sent him to an old friend of mine, a regularly 
educated and once practising physician, but now the head of one 
of our largest surgical instrument establishments in this country. 
With this patient I sent a note telling the doctor that I had just 
operated on the man for the cure of a double Hernia, and 

1 For fuller results, see p. 394. 



190 HERNIA. 

requesting him to fit the case with a nice, suitable truss. After 
the patient had the truss put on by ray friend, the doctor, he 
returned to me, and as it was not a suitable one I sent him back 
to the same place for a better one. 

As I saw no more of him I supposed, from my long experience 
with the manufacturing establishment, that he had been properly 
fitted the second time. On the contrary, to my mortification 
and chagrin, I was soon told by tlie attending physician that this 
second truss was no better than the first, but that when the man 
sat down, it would strike against the back of the chair, and be 
thrown forward off the seat of the rupture, and thus would not 
support and sustain the weakened rings. Of course, our whole 
design in ordering it was to sustain these rings, as the adhesions 
had not yet become sufficiently strong fully to resist the pressure 
of the intestines and other parts against them. 

His physician stated, also, that the patient said that the 

doctor, when he fitted him, made him strain, force down and 

cough all he could. 1 By such treatment there was naturally 

produced some protrusion of the parts, and I said that if he 

had not by this means re-ruptured the man I should think it 

almost a miracle. As, moreover, he assumed the liberty with 

this patient to tell him he was not cured, I took it rather ill at 

first. 

Now I hear you say if this had been my patient I should have 

been indignant at such proceedings on the part of my friend the 

doctor, particularly after I had written to him that the operation 

had just been performed, and after I had in the most friendly 

manner possible requested him to fit the patient with great care. 

Please defer, for one moment, your harsh criticism, for in the 

first place the doctor did iu this case just what most of us might 

1 This story should be taken with a grain of allowance, as my friend, 
who adjusted the truss, says he thinks the patient brought this condition 
of his rupture on himself, and I certainly would credit the doctor sooner 
than any patient. 



GENERAL REMARKS. 191 

have done under similar circumstances. The patient is said to 
be cured, and to all appearance is cured (I may add that I truly 
think that this man was cured, and that such was also the 
opinion and belief of his attending physician) ; now I say, this 
being the case, the doctor did not stop to consider, it may be, the 
young and tender state of the united tissues, any more than many 
others would. This is an operation all are not conversant with, 
and just how strong the parts are and how far they will bear 
straining, all are not supposed to know at present. 

Suppose, too, on the other hand, we were a dealer, fitting, for 
example, a wooden leg, and wishing to sell, would it not be 
natural for us, regardless of the very recent cicatrix, to cause 
the patient to force his amputated limb into the artificial one, 
and to try and convince him that he could walk more miles 
without fatigue with this leg than with the one lost in battle ? 

No, gentlemen, I do not blame my friend for thus treating my 
patient, and it is with no ill feeling that I refer to the matter at 
this time, although it is true that this was my first operation for 
the radical cure of Hernia, and naturally a pet one. I speak of 
the case to show that it proves one thing certain, viz. : that a 
great amount of violent treatment can sometimes be endured im- 
mediately after the operation without a new rupture taking 
place ; for with this man one side, strange to say, did not move 
or protrude in the least, while the other did. 

Still, I would not advise much violence to be done to the 
tissues while they are in a fresh state of adhesion, since their 
condition soon after, nay, for months after the operation, may 
be compared to freshly-glued pieces of wood. Tt is true, there 
will immediately be some adhesion, so as to hold them together, 
but if any force, even of a very slight nature, be at once 
applied, it will cause them to part. Should, however, a longer 
lime be allowed to elapse before force is applied, the pieces 
will be found adhering so firmly that the fibres themselves will 



192 HERNIA. 

separate sooner than allow the wood to part. Just so is it with 
the tissues of the body after this operation. The tenor of 
adhesiveness of the rings and surrounding parts is at first slight, 
but after a period of time the new formation of adhesive fibres 
will often be found stronger in cohesion, because of their con- 
traction and consolidation, than any other part of the dependent 
tissues composing the rings. 

This case is instructive, then, in three ways : First, it shows 
how a severe Hernia may be successfully cured : secondly, how 
much ill treatment a Hernia thus cured may sometimes endure ; 
thirdly, how easily this relief may be forfeited by interference 
with the process of healing, whether in fitting a truss- or by 
making the patients cough, force down or strain in any way, to 
gratify a mere idle curiosity. 

Operations Nos, 3, 4, and 5. — This case is a unique one, and 
in many respects more instructive than any we may ever meet 
again. Mr. P., aged between forty-five and fifty, applied to the 
late Dr. Heaton for an operation, but for some reason was 
deferred. After Dr. Heaton* s demise the gentleman presented 
himself to me for the operation, telling me that he had been 
ruptured for eighteen years and that Dr. Heaton had promised 
to operate on him. I examined him, and frankly told him that 
I did not have much faith that he could be cured by the opera- 
tion, but that if he wanted me to try to effect relief I would do 
so, with the distinct understanding that I did not know what 
the result would be, and that I would not, on any account 
warrant the least relief or cure. 

Accordingly, on the 25th of July, 1879, at 220 Harrison 
Avenue, formerly occupied by Dr. Heaton as his hospital, T 
operated on the man for two of the largest Hernias I have ever 
seen. They were double inguinal, on the left side with a ring 
two inches in diameter, on the right side with a ring one and a 
half inches in diameter. He said it had been well nigh im- 



GENERAL REMARKS. 193 

possible to retain the bowels in their proper cavity by any or all 
artificial means, and so great had been his pain that he was 
constantly longing for the time to come when he could lie down, 
to ease his sufferings. At the time of operation he was wearing 
a very large elastic abdominal supporter and truss combined, 
although neither this nor the " hundred different trusses he had 
at home" could retain the ruptures in their proper position, 
because, as he expressed it, the Hernia? were so large, especially 
on the left side, that they would " boil over " any truss that was 
applied. It is needless to say that the patient was suffering not 
only this physical anguish, but also mental depression. 

In my operation I found it necessary, on account of the greatly 
dilated rings, to inject a larger amount of quercus alba than 
usual. About eight hours after the injection the pulse and 
temperature began to rise, reaching their maximum on the 
second and third day. On these days the temperature was 
99 -5° and the pulse about 90. They now began to diminish 
until on the fifth day only a slight increase over the normal 
condition was noticeable. On the same day he had a free 
evacuation of the bowels, from a dose of Seidlitz powder. 

During all the time since the operation the urine was passed 
normally, and he complained very little of pain, except in the 
immediate vicinity of the rings, where the injection had been 
made. 

On the eighth day after the operation the swelling, which at its 
maximum had extended up as high as the crest of the ileum, 
running along the oblique muscles on both sides, had wholly dis- 
appeared. There was no tenderness around the umbilicus, nor 
any indication of inflammation of the peritoneum, except in a 
very limited spot around the rings. The hernial sac on both 
sides was enormously enlarged and thickened, and on the leftside 
bound down by some adhesion. Upon examining the patient 
in the erect position, I found the Hernias well retained in the 

o 



194 HERNIA. 

abdominal cavity and the rings firmly and well filled, except in 
a small portion of the superior part on the left side. 

Fearing this might dilate, and finally allow a hernial pro- 
trusion, I operated again on August 2nd, on the left side, to 
guard against such an accident. This second injection pro- 
duced phases similar to those in the first operation, with a 
little greater swelling, but on August 11th the swelling began to 
pass away, and everything to assume a normal condition. Now, 
standing my patient upon his feet, there was no protrusion on 
either side, and I thought of discharging him in a few days, 
cured of a most remarkable Hernia. I therefore allowed him 
to sit up, for an hour or two daily, but on the 13th I found that 
he had extended my hour of allowance to the liberty of sitting 
up from morning till night. Secondary swelling immediately 
began to appear, but from the applications of cold water and 
enforced recumbent position, they had diminished on the next 
day to about a normal state. 

The man was continually anxious to return to his home, in 
Lawrence, but both I and the matron urged upon him the 
expediency of remaining at rest a few days longer. I told him 
that there was danger that the effort of the journey might 
produce an abscess, or even loss of life. Tn spite, however, of 
all our arguments and persuasions, go he would, and go he did, 
assuming to himself all responsibility and risk in such a reck- 
less act. Accordingly, at noon on the fourteenth he left our 
care for his home. In consequence of this exertion there was, 
as we anticipated, a return of the swelling and the formation of 
an abscess. He was treated very successfully in his trouble 
by Dr. G. W. Garland, as the following letter will show : — 

Lawrence, Sept. 15th, 1879. 
" Dr. J. H. Warren— 

"Dear Sir,— Mr. P. came to Lawrence Thursday, August 

14th. I saw him the following Friday. It was perfectly 



GENERAL REMARKS. 195 

apparent at that time that he was to have an abscess. It was 
opened August 20th, under ether and a disinfectant spray. An 
opening was made large enough to explore the bottom with the 
finger, which seemed firm. The abscess proper was quite as large 
as a common saucer, and swelling, tenderness and pain extended 
up the groin as far as the crest of the ilium ; another abscess 
formed in the scrotum, just above the testicles and over the 
cord, which was opened August the 30th; still another was 
opened September 10th, just above the original one. The one 
on the scrotum has healed, the others are doing finely. A large 
portion of dead tissue came from the floor of the main abscess. 
The surrounding induration has been treated with tincture of 
iodine, and both hot and cold lotions, and is quite rapidly 
subsiding. 

" I have neglected to mention that after Sunday, the 17th, a 
severe fever followed a chill for a day or two. There is no 
protrusion of the Hernise, and the case, for so bad a one, is doing 
well. Mr. P. is to go to Andover next Wednesday, P.M., a mile 
and a half from Lawrence. He is gaining strength fast. 

o o o 

" Very truly yours, 

"G. W. Garland, M.D." 

On September 26th, Mr. P. called at my office, and I found 
that the principal abscess had been just above the seat of my 
operation, and was still slightly discharging, as was also the one 
in the upper part of the scrotum. There was considerable in- 
duration and a large cicatricial indentation of the parts around 
the lower portion of the ring, extending down to the spermatic 
cord. There was a slight protrusion of the upper portion of the 
omentum, but no sign that the intestines had descended through 
the ring. I ordered cold compresses, with proper supporting 
bandages, and enjoined absolute quiet, in bed. He now regrets 

o 2 



196 HERNIA. 

that he did not remain longer in Boston, instead of hurrying 
home. 

On October 8th I again examined him, and found the swelling 
and congestion still existing, although greatly diminished. I 
found that instead of a good supporting bandage he had applied 
a very frail and wholly inadequate affair, and I now applied a 
delicate, French double truss, and ordered frequent bathing of 
the parts in cold water and carbolic acid. It will be remem- 
bered that he told me at the time of my first operation on him 
that he had been ruptured eighteen years. He now told me 
that his mother had informed him that he had been born 
ruptured, and that his father had taken him when a child to 
have a truss adjusted. I told him that had I known this before 
I operated I should on no account have taken the risk of 
operating on such an enormous congenital Hernia. My opera- 
tion in tli is case had been performed with the simple extract of 
quercus alba and morphine that Dr. Heaton recommended, but 
with a needle of the Doctor's that I had improved by making 
two more orifices near the point. 

Although performed with so unsatisfactory a needle and 
mixture, it establishes three very important points : first, it gives 
us the pathology of such cases soon after the operation ; second, 
it shows how very important it is, if we would escape dangerous 
consequences, to insist upon and enforce rest in the recumbent 
position, together with constant applications of cold water at 
the least appearance of a secondary swelling and inflammatory 
process ; third, it shows what a wonderful result can be obtained 
by the operation in cases hitherto deemed incurable, as e.g., 
congenital and enormously large HerniaB. 

January 29th, 1 880. I examined this patient, and find he 
is perfectly cured on one side ; on the other side there is some 
omentum, protruding, which will require another injection, and 
with the mixture I am now using I hope to fully close up the 



GENERAL REMARKS. 197 

rings, dS it is more stimulating than the mixture of Heaton 
that I used in my operation on him. He is very anxious 
to have me try again, which I promised to do as soon as I 
think proper. 

Operations Nos. 6, 7. — Having found these cases so fruitful 
in instruction and encouragement, I undertook my sixth operation 
with increased confidence. Mr. M., aged sixty-two, had been 
ruptured when eleven years old. This rupture, oblique inguina 
on the left side, continued to enlarge until he was twenty-one 
or more. 

For nine or ten years it gave so little trouble that he did not 
think it necessary to wear a truss. Ever after that time, how- 
ever, he wore one, until July 30th, 1879, the day I operated on 
him. The hernia was an inch and a half in diameter, and 
protruded about the size of a duck's egg. I injected twenty 
minims of fluid extract of quereus alba with one tenth grain of 
morphia. He went through the customary phases — slight rise 
in temperature and pulse, then a gradual subsidence — until, 
after eight or ten days, he returned to his normal condition. 
On the 11th of August, only twelve days after the operation, he 
rode out, free from his rupture, without even the slightest bulging 
of the tissues so long dilated. 

We have now come to the interesting and instructive part of 
the case. I have said that so far as I could ascertain by careful 
examination, in the erect and recumbent position, the ring was 
entirely occluded with firm surrounding parts. 

The confidence both of myself and of the patient in the 
perfect results of the operation was so great that it is true we 
applied only a supporting bandage, and the man returned to his 
usual occupation. In this condition he remained for nearly two 
months, when, relaxing in his attention to the proper support, 
he suffered a slight protrusion of the ring and at the same time 
a descending of the sac. 



198 HERNIA. 

To remedy this protrusion I re-injected him on October 6th, 
with my mixture of quercus alba, alcohol, morphia and sulphuric 
ether. This injection created a slight local disturbance, but no 
increase of pulse or temperature, and produced a further contrac- 
tion of the ring. Although it was not so fully contracted as after 
the first operation, still it was sufficiently contracted to retain 
the hernia within the abdominal cavity. Unwilling longer to risk 
a bandage, I ordered a light and soft French spring truss, to wear 
six or eight months, which he continued to wear until December 
9th, when he again presented himself to me, and this time with 
a strangulated Hernia on the right side. It was a most curious 
case. 

I reduced this new rupture and fitted the man with a soft 
double French truss. Having much soreness on this right side, 
extending down to the spermatic cord, he was ordered to resume 
the recumbent position in bed. 

In spite of various soothing applications the pain continued 
for several days, extending now to the testes and scrotum, pro- 
ducing intense neuralgia in the former, with irritation and 
swelling. This state of affairs lasted with more or less acuteness 
until December 23rd, when I applied a bandage with compress, 
and allowed him to go to his office. I applied the compress 
bandage instead of the truss, from fear that too severe a pressure 
on the springs of the truss might produce violent irritation of 
the still tender parts. During all this time since the operation 
for Hernia I made frequent examinations, and found that since the 
last injection the ring on the left side had continued constantly 
to contract, so that the man may now consider himself healed 
on that side, at least. 

The lesson here to be learned is, first, that had he been more 
careful, after once firmly closing the ring, to support it properly 
for a little length of time, so that nature might complete the 
consolidation, we should never have needed to make a second 



GENERAL REMARKS. 109 

injection ; secondly, that the patient must be made to be careful 
of himself until nature has done her work, and that he must not 
unwarrantably presume upon his perfect recovery until several 
months have elapsed ; thirdly, that for a long period after the 
injection the fibres of the surrounding parts continue to contract 
and consolidate, so that cases where we at first may be inclined 
to think we have not yet obtained a full occlusion may ultimately, 
if properly attended and cared for, become perfectly healed. 
Finally, we can again see that the long duration of Hernia is no 
bar to a radical cure by injection. For this patient has been 
ruptured forty- two years. 

The first of these operations I performed with the old original 
needle of Dr. Heaton ; the two latter with his needle as I had 
improved it by adding more orifices for the exit of the fluid. I 
have detailed them minutely and fully, that you may see what 
great obstacles lie in our path, and how the slightest inattention 
or carelessness, either on the part of the operator or the patient, 
may cause a deal of trouble, not to say danger. It cannot be 
too solemnly impressed upon the patient that the success of the 
after treatment, (and that means the success of the whole 
operation) depends as much upon him as upon the operator. If, 
then, we retain all the valuable instruction these unfavourable 
symptoms inculcate, we may with a little cheerful perseverance 
wonderfully triumph by our success. 

I will now give a few of the cases that T have had since the 
time that I reduced the operation to a more scientific basis, as 
I believe, by perfecting both the instrument and the injecting 
fluid (see New York Medical Record of October 18th, 1879). 
It will be seen that with this new instrument and fluid I 
encounter less danger, cause less constitutional disturbance, 
less unnecessary irritation and more intense local action where 
it is needed, and there alone, than could ever be possible by 
the crude methods formerly used. 



200 HERNIA. 

Operation No. 8. — F. M., aged twenty-eight, had for two 
or three years suffered, intensely, and had consulted several 
physicians, some treating him for disease of the liver, others 
for disease of the kidneys and bladder. The true seat of dis- 
tress was an inguinal Hernia upon the right side, which was 
very annoying and painful, since the Hernia was exceedingly 
sensitive and irritable. 

I found the protrusion was slight, with a ring about one 
inch by half an inch in dimension, and operated on it for 
radical cure, on September 6th. The patient made a rapid 
and full recovery, and sixteen days after the operation accom- 
panied me to New Fork. Among the physicians who there 
examined him was Dr. R. F. Weir, who was fully convinced 
that there was a complete occlusion of the hernial ring. The 
man was ordered to wear a bandage, and was then discharged 
from my care. I saw this patient on January 24th ; he is 
still free from his rupture. 

Operation No. 9. — L. B., aged four years, was, after etheri- 
sation, operated on, November 4th, for a congenital umbilical 
Hernia, about three-quarters of an inch in diameter, and in 
appearance and size not unlike a red acorn. I injected eight 
to ten drops of the mixture. Passing through the usual slight 
feverish excitation, she was discharged from my care after two 
weeks' time, fully cured. 

Operation No. 10. — On December 18th I operated upon 
J. R, aged forty-one, for direct inguinal Hernia on the right 
side. The opening was in size one inch by three-quarters of 
an inch, and had existed for more than two years. I was 
assisted by Dr. Joseph Redfearn, Jun., of Ashland, whose patient 
the gentleman was. I injected about fifteen minims of the 
mixture. The only pain was a sharp smarting for about five 
minutes after the operation, and on January 1st Dr. Redfearn 
and myself examined him, and were satisfied that the man had 



GENERAL REMARKS. 201 

fully recovered, with a perfect occlusion of the ring, and was 
ready to be discharged. I had a note from him on January .13 th, 
and he is well and free from all trouble from his Hernia. 

Operation No. 11. — Mrs. M., aged fifty-six, had had 
a femoral Hernia on the right side for more than thirty 
years. The opening through the tissues was flat oval, about 
one inch and a quarter by three-quarters of an inch, with a 
protrusion the size of a large goose egg. On December 25th 
I operated upon her, injecting about ten drops. She had just 
recovered from typhoid pneumonia, and still had a slight cold, 
so that it was only at her urgent request that I operated when 
I did. The smarting pain from the injection was very severe 
for five or ten minutes. On the second morning after the 
operation her cold was much worse, attended with pleurisy 
on the left side and a heavy cough, and her food had caused 
her to vomit. For three or four days her temperature was 
100 and her pulse about 95, but whether from the fever or 
the injection could not be determined. On January 6th I 
caused her to assume the erect position, and found the rings 
occluded and the intestines completely retained in their cavity. 
So firmly occluded are the rings that, as she is rather fleshy, 
a little dimple is seen over the seat of the operation. 

January 15th. She is cured of rupture. 

Operation No. 12. — Mrs. L., aged forty-five, of delicate 
constitution, had a very painful Hernia on the right side, which 
had been strangulated three times, twice with great danger to 
her life. The Hernia had existed for fifteen years, occurring 
from a strain in child-bearing. It was very painful, and pro- 
truded about the size of a common cowry. There were two 
openings through the crural ring, the larger, from which the 
protrusion took place, near the femoral vessels. This opening 
was about three-quarters of an inch in length and measured 
three-eighths of an inch in width. 



202 HERNIA. 

I operated by injecting about ten drops of my usual mixture. 
She was in the evening but slightly feverish, with pulse about 
normal, 78. The next day the parts about the ring were tender, 
and covered with a profuse effusion of lymph. She suffered 
great pain through the back, right hip and limb, owing much, 
as she thought, to the constrained position of lying on her back, 
as she had often suffered equally severely for months at a time. 
A pill of ext. hyoscyami, lactucarium, and morphia was given 
her, to secure rest and ease from the pain. Third day — Her 
temperature and pulse are about the same as on yesterday. I 
afterwards found that the cause of her pain was her periodical 
turns appearing. Upon examination, January 12th, the rings 
were found perfectly occluded and she cured of her hernia. 

July 10th. She is free and cured from her painful Hernia, 
and a happy woman. 

In all these operations I find that in order to insure success I 
must produce a certain, though limited, amount of inflammation 
of the surrounding parts. You will see that I have aimed to 
produce this. Dr. Heaton considered the inflammation very 
dangerous, and said that in his operations it seldom occurred. He 
meant peritoneal inflammation. Dr. Davenport, 1 editor of Dr. H.'s 
work, as directed by Dr. H., worked up a sort of pathology, to 
the effect that only, " tendinous irritation," as they call it, was 
caused, and no inflammation. I find that Dr. Heaton was 
mistaken in his pathology, as it is impossible to contract and 
occlude the rings without an inflammation, to cause an effusion 
of plasto-lymph. I learned, too, from Dr. Heaton's old matron, 
a very intelligent woman in such matters, that Dr. II. always 
got more extensive inflammation, swelling, and often abscesses, 

1 No disrespect is here intended to so good a man as Dr. Davenport, but 
this is nevertheless a fact, as told me by his cousin, Dr. D., of Boston, 
who said he knew that Dr. Davenport had to work up a sort of pathology 
to meet the statements of Dr. H. in his operations. 



GENERAL REMARKS. 203 

when he was successful, than I ever get in my cases. This 
excessive inflammation was probably due to the crude injecting 
mixture and instrument which he used. Indeed, I am often led 
to wonder that he ever succeeded with his operations at all. 

I have now gone over all the ground that Dr. Heaton passed 
over, and have performed upon all the various kinds of Hernia 
which he operated upon, and I feel confident that my results, to 
say the least, have been as successful as his, in the same given 
number of cases. 

In fact, the question whsther Dr. Heaton ever cured any one 
of rupture, has been asked by those whose opinion is entitled to 
much weight. I can answer in the affirmative, because I have 
examined a large number of those upon whom he has operated 
for Hernise of from one to twenty years' standing. 

That he failed in many cases is also true. But in all his 
failures we should find, if we traced the operation, that there 
was only a slight infusion and only the most limited amount of 
inflammation, or what in his work is styled tendinous irritation. 
It is a well-known fact, that if we would produce a blister with 
cantharides, for instance, we must, in order to get an effusion of 
plasto-lymph, destroy the cuticle and create a given amount of 
inflammation. The same holds good in this operation. The 
parts must receive a certain amount of irritation from some stimu- 
lating material, to excite the secretion of this lymph. The more 
plentiful the effusion the more sure we are of strong adhesions 
and attachments, which will organise into fibrous bands, not 
unlike the cicatrix of a severe scald or burn. This draws and 
binds together the hernial rings and surrounding parts, and 
when properly performed retains the hernial protrusion in its 
proper cavity, more firmly than ever before, in many cases. 

You will see that I have given you the history of twelve 
operations on genuine ruptures of various kinds. This does not 
include all that I have operated upon, but only a few interesting 



204 HERNfA. 

cases. Of these twelve the first two were partial failures, and 
one later on. Two of these are soon to be re-operated upon, and 
I have no doubt that, with the mixture of such a stimulating 
nature as I now use, they will be permanently cured by the 
second injection. I have some doubts as to the possibility of 
retaining the large congenital Hernia, but as the patient is very 
anxious for another operation, I presume I shall try it. I have 
freely expressed all my doubts to him, but unless I operate upon 
him he will not be contented, nor shall we know whether such 
cases can be successfully treated. This includes all the 
unfavourable cases that I have had in my operations thus far. 
I might cite many other successful cases, but I have presented 
a sufficient number to give an idea of the results of the 
operation. 

You will see, gentlemen, that I have felt it my duty to 
develop this operation with open bands, concealing nothing, 
but recording careful observations on all my cases, keeping 
nothing to myself in a selfish way, but offering everything in 
my power to the profession, in order to establish a legitimate 
operation. Others may have undertaken to relieve the ruptured 
sufferers by methods known only to themselves ; I am determined 
to do what I can to demonstrate to myself, and I trust to you, 
that this operation, when properly performed, possesses many 
advantages over every other now known for the cure of this dis- 
tressing malady. Whatever discouragements, whatever obstacles, 
whatever successes I have met, all have been freely given to the 
scientific advancement of surgical knowledge. To say that this 
operation for the radical cure is simple, and when carefully used 
by skilful operators presents no greater danger and no more 
unsuccessful results than other well-known surgical operations, 
is only the barest justice to its past and present success. 

I am, therefore, encouraged to hope that other members of 
the profession will test it in the course of their practice, and 



GENERAL REMARKS. 205 

present us with reports upon the cases, that we may all, 
dispassionately and without prejudice, judge of its true value. 

In reply to the gentleman who has performed Wood's opera- 
tion successfully with wire, catgut, or pins, while these ligatures 
or the pressure of a truss may cause suppuration and an absorp- 
tion or melting away, as he termed it, of the plasto-lymph 
effused, still I must maintain that the condition of the parts and 
the materials that I use produce very different effects, in the 
quantity of lymph effused, as well as in the permanency of the 
effusion. As this gentleman has never performed the operation 
tor the cure by injection of the hernial rings, I cannot take 
his statements as of any authority in regard to the melting 
away of the lymph after my operation, whatever may have been 
the results, good or indifferent, after his operations by other 
methods. 28 

Another gentleman's experience of twelve operations, with 
only one success, goes only to substantiate more fully what I 
discovered after my second operation, that a more stimulating 
mixture was required and a better instrument than the one 
recommended by Dr. Heaton. Another disadvantage he might 
have had is that his patients occurring in hospital practice were 
anaemic, not properly nourished, and therefore not in so favour- 
able a condition as regards their systems as those in private 
practice. 

Whenever Dr. Heaton's instrument and mixture are used 
the results will be very uncertain and unsatisfactory ; although 
an abundant inflammation will be set up, the effusion of lymph 
will be proportionally small. In fact, the great cause of failure 
is not in all cases, as is commonly supposed, the lack of proper 
after- support, but that the lymph attachment is severed by 
muscular contractions, and the lymph readily absorbed. 
i I am not at all astonished at the questions asked as to my 
operation, when I talk with gentlemen at our medical meetings 



206 HERNIA. 

and read the numerous letters of inquiry which T receive. Fot 
if one has not seen the operation and had it explained to him, 
he can have only the faintest conception of it, be he ever so 
good a surgeon or operator in general surgery. 

Physicians and surgeons of no little renown have asked me 
if I pass the needle through the scrotum and follow up on the 
spermatic cord ? Another asks if 1 go through the columns, 
and at precisely what point I cut through the rings ? Some 
think there must be great danger in operating on Umbilical 
Hernia, since, as they say, we penetrate the peritoneum. In 
reality, the needle is not passed either into or on to the 
peritoneum. 

Others think the inguinal region must be dangerous, because 
of the numerous vessels and nerves. The truth is that the 
umbilical region is the safest region to operate upon, inguinal 
less safe, and femoral the most dangerous. None should operate 
upon the latter, unless they are experienced. 

Upon infants, as I have before said, 1 have never operated. 
The youngest patient was four years old. Mechanical appliances, 
such as a good truss or elastic bandage, 1 have found productive 
of srood results. 

I prefer a bullet, partially flattened and fastened to a linen 
bandage, because the compression of the abdominal muscles by 
the elastic bandage prevents their development, and conse- 
quently the closure of the rings, and also because the muscles 
are liable to be thinned by the constant pressure and for ever 
weakened. 

In conclusion, I would say that above all the congratulations 
from gentlemen of note in the profession, the resolutions and 
the honorary membership of the Medical Society of Otsego 
County, New York, I esteem the commendation of my friend, 
Dr. B. Codman, who has, as is well known throughout this 
country, for many years attended to the mechanical treatment 



GENERAL REMARKS. 207 

of Hernia. He says, "I believe you have at last perfected 
this operation, and I know that with your instrument and fluid 
you will be successful in the treatment of Hernia by injection, 
and will have greater success than has been hitherto met with 
by any one ; with the adjustment of a proper temporary truss 
after the operation, a permanent closure of the rings will 
crown your efforts, and you will receive your reward from an 
appreciative profession." 



CHAPTER VIII. 
Treatment of Strangulated Hernia. — Taxis. 

The treatment of Strangulated Hernia is one of the most 
important of surgical operations. We have not only to effect a 
reduction of the strangulated intestine and to remove the con- 
striction, but also to treat the peritonitis. We accomplish the 
reduction by the operation of taxis, by which we mean all the 
manual methods used for the purpose of returning the protrud- 
ing intestine into the abdominal cavity. The peritonitis may be 
excited either by the compression caused by the strangulation 
or by the attempts and efforts at reduction. We may in some 
cases have to deal with a peritonitis, the result of strangulation, 
increased by a peritonitis, the result of taxis. The taxis, how- 
ever, when properly done, is rarely, if ever fatal, if a judicious 
after treatment be adopted. 

The following valuable hints from Birkitt, I trust I may be 
pardoned for extracting verbatim. 

"The principal circumstances to which attention should be 
; directed are as follows : 

u 1. The kind of variety or the Hernia regarded in its 
anatomical relations. 

" 2. The duration of its existence ; whether it be of old 
standing and slow formation, or of recent and sudden develop- 
ment. 



TREATMENT OF STRANGULATED HERNIA. 209 

"3. The constitutional condition of the patient at the im- 
mediate moment, as influenced, by the present illness. The 
hour at which vomiting commenced ; and the variations which 
have taken place in the composition of the fluids vomited, 
should be determined with exactitude. 

"4. The state of the tumour. Its usual size when not causing 
illness ; its bulk before vomiting commenced ; the changes 
which have taken place in it during this stage; the pains to 
which it gives rise, if merely local or extending into the 
abdomen, with or without manipulation; the condition of its 
coverings ; its probable contents, so far as may be conjectured 
by the evidence, assisted by touch and sight. 

" 5. The treatment already adopted by the patient, the friends, 
or other persons before the observation of the surgeon." 

In employing the taxis it is necessary, first, . to have the 
bladder evacuated either naturally or by the catheter, and also 
the rectum; secondly, to gain a relaxation of the abdominal 
muscles, and. thirdly, it is always advisable to administer an 
anaesthetic and preferably sulphuric ether. 

The position to gain the relaxation of the abdominal muscles 
is important. After placing the patient upon his back with a 
pillow under his buttocks to elevate the pelvis, and with his 
head and shoulders raised, the thighs should be flexed by 
bending them up at nearly right angles to the trunk, and 
slightly rotating them inward. 

The surgeon, getting into the position which gives him the 
greatest control of the tumour and the freest action of his 
hands, should make gentle manipulation upon the tumour for 
from two to five minutes, when, if reduction be not effected, he 
should try the application of cold to the parts. This application 
can be made with powdered ice, and sometimes by pouring a 
small stream of ice water from a considerable height upon the 
tumour and surrounding parts. The tumour can now be gently 

p 



210 



HERNIA. 



squeezed between the thumb and finger and drawn outward to 
relieve the gut of its cramped position before renewing our 
manipulations. Should this not succeed we may, after a few 
minutes of rest, pour sulphuric ether upon the parts and fan it 
to cause a rapid evaporation. This evaporation causing intense 
cold contracts the superficial integuments, the sac and the 
included intestines much more rapidly than it does the solid 
fibrous Poupart's ligament ; hence if we immediately apply 
gentle taxis we may often succeed in reducing cases hitherto 
supposed to be irreducible without the use of the knife. 
Changing the position of the patient from side to side will 
often aid in reduction by the specific gravity of the parts 
tending to suck the intestines into their proper cavity. If 
this be not sufficient to accomplish our purpose, the injection of 
large amounts of hot water per rectum is useful by distending 
the intestines and dragging them into the abdomen. 31 

To obtain a proper relaxation of muscles it has been recom- 
mended to use blood-letting to the point of fainting, to inject an 
infusion of tobacco or to administer tartarised antimony, opium, 
cannabis indicus, hyocyamus, stramonium, or belladonna. But 
although these have all been tried with more or less success, 




Fig. II. — Reduction of Scrotal Hernia by Taxis. 



TREATMENT OF STRANGULATED HERNIA. 211 

they are not measures which in these days of anaesthetic I 
would recommend, since by anaesthetic we gain a greater relaxa- 
tion of the muscular system than is otherwise possible, and 
avoid the deteriorating and exhaustive influences of these drugs 
I have mentioned. 

The taxis should be continued at intervals of a few minutes 
for from thirty minutes to three hours according to the alarming 
symptoms, the condition and vitality of the patient, and the 
length of time since the Hernia became strangulated. Of these 
the surgeon can judge when called to the case. In general 
we may say that we can treat old and large Hernia?, accom- 
panied by omentum and occurring in persons of advanced years, 
with greater impunity by prolonged manipulation than small 
Hernia) with very acute symptoms. These symptoms will have 
shown themselves by violent retching, pain in the parts, and 
a feverish excitement of the system accompanied by giddiness 
or delirium. Femoral Herniae are to be treated with the greatest 
gentleness, as with too violent pressure and manipulation there 
is great danger of rupturing and fatally injuring the intestines. 
Of all this let the younger men of the profession take good 
warning. In treating a strangulated Hernia let no undue 
violence be used. It can do no good and may result in extreme 
danger to the life of the patient from the forcible constriction 
of the inflamed intestine against the constricting ring. If the 
inflamed state has passed to gangrene we should never attempt 
the taxis for fear of fatal peritonitis. From the observation of 
many years I am convinced that the taxis is often too long con- 
tinued before resorting to the operation of kelotomy, and I 
feel as confident that thousands of lives that are lost might have 
been saved by employing this operation in due season. The 
following quotation from Surgical Anatomy, by William Ander- 
son, will illustrate my point. " I know of no excuse that would 
apologise for the delay which we generally witness before this 

p 2 



212 HERNIA. 

operation is resorted to, or which would authorise the surgeon 
who is to be the operator in allowing half a dozen consultants 
to take their turn in squeezing the tumour under the pretence 
of giving full trial to the taxis." 

To illustrate a position for the patient, which in my opinion 
is very favourable for the operation of taxis, as well as to show 
the permanency of the ordinary operation by injection, I give 
the following rare form of femoral Hernia occurring in a patient 
of mine previously operated upon for inguinal Hernia upon 
the same side. 

The history of this case is as follows : Mrs. M. L. L.. of Athol, 
Mass., aged forty-five, was ruptured, at the time or soon after the 
birth of a child, some ten or twelve years ago. On right side the 
Hernia was oblique inguinal with protrusion of the size of an 
English walnut. It had been strangulated twice, both times 
with near loss of her life. It was reduced once by H. A. Dean, 
M.D., a cautious and skilful medical gentleman of fine scientific 
attainments in the profession, and the second time by Dr. Lynde 
in company with the above-named physician. 

Dr. L. is also a physician and surgeon highly esteemed in the 
profession as an expert diagnostician. These gentlemen saw 
the patient soon after the Hernia became strangulated, and after 
etherisation succeeded with some difficulty in reducing the 
rupture by taxis. 

This Hernia was very painful and difficult to retain with a 
truss. At the suggestion of her physician she applied to me for 
a cure by injection. Being on my vacation I did not see her 
until my return in the fall of 1879. It still. gave her great pain 
and was very sore from the truss. I operated on her in the 
first part of January, 1880, with success, by injecting fifteen 
drops of fluid extract of quercus alba, alcohol, ether, and mor- 
phia. This Hernia was well retained and the rings occluded. 
In the early part of May, 1880, she had an attack of colic. 



TREATMENT OF STRANGULATED HERNIA. 213 

She felt something give way, and soon after had pains and 
symptoms of strangulated Hernia. Dr. Lynde being called 
tried to reduce the Hernia by taxis. After continuing his 
attempts for the greater part of a day, he thought that as I 
had once operated on her she had better again come under my 
care. As the seat of rupture and strangulation was not well 
defined, he in his diagnosis leaned to the opinion that it was an 
oblique inguinal, the same that had twice before been reduced 
and on which I had operated; but was not certain since my 
operation had left more or less cicatricial tissue, and had there- 
fore a tendency to blind completely the seat of strangulation. 
This with the peculiar form of rupture was sufficient to lead the 
most experienced astray in his diagnosis. 

The patient arrived in great pain in the night of April 29 ; 
with parts much inflamed and swollen. With the assistance of 
Dr. Broughton, I placed her under the influence of ether, and 
upon a most careful and thorough examination by both of us, 
we found the rupture was femoral, and about 2-| inches from the 
oblique inguinal that I had succeeded in curing. It had de- 
scended on the outer side of the femoral vessels and beneath 
the femoral artery, the pulsations of which could be distinctly 
felt. The sac was preceded for a distance by the sheath of the 
pectineus muscle. After it had passed down beneath the femoral 
vessels it turned a short angle toward the left side, the largest 
part of the swelling being immediately beneath the seat of her 
former Hernia. 

This diagnosis was sustained differentially by a most thorough 
examination, with some efforts to reduce it through the inguinal 
rings. Finding no opening, since the rings, as I have before 
said, were firmly occluded, T began to investigate and examine 
the crural ring, and soon discovered the seat of strangulation, 
as I have abcve stated, firmly held. 

It should be borne in mind that the diagnosis was much more 



214 HERNIA. 

than usually obscured by the parts being so inflamed and swollen. 
After placing the patient in every conceivable position, such as 
elevation of hips, curvature of spine, limbs flexed on abdomen, 
&c, and after working with great earnestness at reduction by 
taxis without gaining in the least on the strangulation, I thought 
of suspension. The patient being very slight, the limbs were 
seized under the knees by Dr. B., who stood over her, and I 
again worked with great ardour, but failed to gain any reduction 
of the strangulation. I was about to perform kelotomy on her, 
when, after further consideration of the anatomy, it occurred to 
me that if I forcibly flexed the thigh toward the left shoulder it 
would bring the obturator and other muscles, together with 
Poupart's and Gimbernat's ligaments, into a greater state of 
relaxation. On the first trial in this position of the parts, the 
Hernia was returned into the abdominal cavity, to the delightful 
sensation that rejoices the anxious heart of the operator. 

On June 13, I was at Athol to operate upon this femoral 
Hernia. As the patient was not properly situated in her house- 
hold affairs, the operation was deferred until the coming autumn. 
At that time I examined her in the presence of her attending 
physician, Dr. Lynde, and before Drs. Oliver and Parsons, of 
Athol, and Dr. Alcott, of an adjoining town, and demonstrated 
to their perfect satisfaction the seat of the oblique inguinal 
and of the late strangulated femoral Hernia. The latter was 
still somewhat tender from the strangulations as well as from 
our efforts at reduction several weeks before. This shows, also, 
better than anything I have yet seen, the permanency of my 
operation on reducible Hernia? by injection, for there must have 
been considerable force upon all the parts before she became 
ruptured in the femoral region. Still the injected rings of my 
first operation remained firm and strong, and to-day retain 
the rupture without any protrusion whatever. 

This then is a very instructive case, first, in proving my 



TREATMENT OF STRANGULATED HERNIA. 215 

operation to be permanent, and secondly, in being a form of 
femoral Hernia seldom seen. Even the older writers have 
diagnosed or mentioned this form of Hernia very rarely, Yelpeau 
and Cooper giving only two or three instances of this peculiar 
form. Thirdly, it will always serve as a guide to me in Hernia 
of this form, by teaching me to throw the leg of the patient 
toward the left shoulder, if the rupture be on the right side, and 
vice versa if on the left side, and to flex the thigh forcibly on 
the abdomen. Since this will give us the greatest possible 
relaxation of the muscles and ligaments that hold the intestines 
in strangulation, and allow by this relaxed state an easy 
reduction. 

If, for study, one will take the cadaver and experiment he will 
find this position the very best for reduction. I would state that 
this form of strangulated Hernia is rather difficult to handle by 
injections, owing to the close proximity of the vessels supplying 
these parts, sometimes further complicated by fine branches of 
the obturator and epigastric arteries which are thrown im- 
mediately over the point of rupture just beneath Poupart's 
ligament and at the angle formed by this and Gimbernat's 
ligament, at or near the junction of the pectineus and other 
muscles in this triangle. Greater care must be used in the 
operation for this form of Hernia than in any other, from the 
liability to penetrate these blood-vessels. Study well each 
individual case before proceeding to operate, or you will cer- 
tainly do more mischief and harm than good to the patient 
submitted to the operation by injection for the cure of femoral 
Hernia by closing the crural ring. 

Finally, after we have exhausted every effort of taxis by the 
various means above mentioned, before resorting to herniotomy 
we must consider whether it is not best to apply the aspirating 
needle (Fig. 40) to the distended sac and intestine, since by 
relieving the tumefaction of gas or other matter we can often 



216 HERNIA. 

quite readily reduce the strangulated parts. For this purpose I 
use a need]e of my own device, of a thin i,val section, which 
will be found very advantageous since coaptation of the wound 
takes place much more readily than when the common needle, 
round in section, is used. This is apparent to any one con- 
versant with the wounds made by a round or flat oval instrument, 



Pio. 89.— Aspirating Needle. 

i 

When we are obliged to cut down upon the parts, to return 
strangulated Hernise, it will often be found the best way to 
evacuate the gas and fluid w T hich may be present in the sac 
before we divide Poupart's ligament, as by so doing we may be 
able to return the strangulated parts without carrying an in- 
cision so far into the parts, owing to the diminished volume 
of the tumefaction. 




Fso. 40. — The first Aspirating Needle for tapping hernial sac in cases of Strangulated Hernia. 

This fig. represents a trocar, invented by a farmer In Athol. Mass., to relieve himself of 
Strangulated Hernia while his physician was gone to get his instruments to perform herniotomy. 
The patient thought he would tap the tumefaction, and by so doing reduce the rupture, in 
which he fully succeeded. This is one of the earliestcasesof the aspirating needle being applied 
to restore Strangulated Hernia. It was given to me by Dr. James Oliver, of AthoL He said 
the patient made uie of it on himself twenty-eight years ago, as above described. 



CHAPTER IX. 

Kelotomy ov, Herniotomy. 

If taxis does not succeed, and the more serious operations 
of kelotomy or herniotomy be decided to be employed, 32 it is 
ordinarily performed in the following manner, although I have 
some suggestions and improvements that very much simplify 
the operation. . Always supposing the patient to be under the 
influence of an anaesthetic, the patient is placed upon his back 
in much the same position as in taxis. 

The bladder being evacuated, and the pubic parts shaved, the 
first step is to make an incision through the skin and superficial 
fascia over the prominence of the tumour, beginning at the 
superior extremity, and terminating near the base, and varying 
in length from an inch and a half to three inches, according 
to the size of the Hernia. This incision may be linear, crucial, 
Y-shaped, or of the shape of an inverted V, and is to be made 
through layer upon layer of coverings until the hernial sac is 
reached, the groove director being used to bring to view the 
deeper seated structures, and it being always a good rule to have 
a large external wound, but as small an internal one as possible. 
" In inguinal Herniie this incision should be made along the 
line of the inguinal canal, from the internal to below the 
external ring; in femoral, over or on the inner side of the 
crural ring, either in a vertical or oblique direction, in the course 



218 



HERNIA. 



of Poupart's ligament, the former being preferable." * The sac 
will appear to our view of a bluish and vascular appearance 
in recent Hernise ; thick and opaque in older Herniae. It should 
now be pinched between the thumb and finger, and the opposing 
surfaces rubbed against one another which could not be done 
were it anything beside the sac. The diagnosis can be confirmed 
by pricking the sac with a small needle. If this puncture be 
followed by a few drops of serous fluid our previous diagnosis 
will be confirmed. An opening is now made into the sac just 



Umbilical 
Ring 




External 
Jtituj 



Obturator 



Fro. 4L 



large enough to admit the point of the director, and the division 
carried upward and then downward, allowing at the same time 
the escape of the contents of the sac. In recent strangulations 
this fluid is small and sometimes absent ; so that we should be 
guarded not to carry our dissection to too great an extent. The 
forefinger is now introduced as far as possible to search for the 
seat of obstruction at the superior part of the sac. The probe 
pointed bistoury is carried flatwise along beneath the stricture 
which is divided by bringing the edge of the knife against it. 

1 Bryant 



KELOTOMY OR HERNIOTOMY. 219 

An absolute rule should be observed as to the direction in which 
this incision is to be made. We wish to avoid the epigastric 
artery. In an oblique inguinal, the artery is internal to the 
neck of the sac ; in direct, it is external to the sac, but since 
old oblique Hernia? so often simulate direct Hernias in appearance, 
the safest rule for cutting is to cut neither outward nor inward 
but directly upward. 

Usually only a very slight incision will be necessary, perhaps 
only a line and a half in length. 1 After removing the dislocated 
viscera and sac from the seat of strangulation, we carefully re- 
place all the abdominal parts that have escaped, that being 
reduced first which protruded last, and of course the bowel 
before the omentum. The wound is now drawn together by 
sutures, and the dressing completed by adhesive plaster, com- 
press and a spica bandage. 2 The patient should now be made 
as comfortable as possible in bed, cold water slightly acidulated 
with carbolic acid being applied under the compress, and re- 
newed from time to time. Morphine or opium should be 
administered, both to secure rest and also to secure the patient 
against that inflammation always to be dreaded — peritonitis. 
The spica bandage and compress should be continued until the 
patient can bear the pressure of a truss, when a properly 
adjusted one should be applied and worn. 

A few of the many modifications of directors and hernia- 
tomes are here illustated. Some are very useful, while others 

1 In our operation of Kelotomy always remember that it only requires 
the cutting or severing but a few fibres of Poivpart's ligament, and it is as- 
tonishing how very small an amount of this ligament, on becoming divided, 
will release a strangulated sac or intestine, so as to be readily reduced into 
the abdominal cavity. Bear in mind while dividing this ligament to cut as 
little as possible, for too much cutting here leaves our patient in a much 
worse condition for the descent of his rupture than before strangulation, and 
more liable to become again strangulated by a too free division of these 
ligaments. 

2 See figure of spica bandage on page 169. 



220 



HERNIA. 




Fig. 42.— Cooper's Hornia Knife. 




Fia. 43. — Peter's Hernia Director. 




Fio. 41.— Hernia Director. 



Fiq. 1. 




Fig. 45. — Allis' Herniotome. 



Fig. 46.— Levi's Director. 




Fia. 47.— Stewart's Hernia Knife. 




Fiq. 4S.— Hinge Hernia Director. 



KKLOTOMY OR HERNIOTOMY. 221 

are seldom resorted to. The author's instrument (p. 239) will 
take the place of all of them, as it simplifies the operation and 
gives great security from dangerous consequences. All that 
is absolutely necessary to use, I find, is a short bistoury, 
Dr. Golding Bird's Torsion forceps, needles armed with silver 
wire or carbolized cat-gut, and my herniatome. No director is 
needed as the herniatome combines director and knife. 33 



OPERATION WITHOUT OPENING THE SAC. 

The return of the hernial sac is not prevented merely by 
the narrowness of the constriction ; it may also be due to adhe- 
sions which have formed either between the intestines and sac, 
or between the sac and the adjoining tissues. The existence of 
these anatomical and pathological adhesions led early operators 
to the belief that it was necessary, in these cases at least, to 
open the sac. Later surgeons have for many years, however, 
realised the dangers of such, an operation, and have come to 
believe that there is not so urgent a necessity as was formerly 
supposed. They divide the stricture external to or without 
opening the sac. By this means the peritoneal cavity is not 
exposed, the danger from peritonitis is reduced, the inflamed 
intestine is not exposed to the atmosphere or to the bands of 
the operator, and the risk of hemorrhage into the peritoneal 
cavity, from arteries that have been cut is entirely absent. 34 To 
sa}', however, that the sac is never to be opened, would be in 
my opinion as erroneous a conclusion as to say that the sac is 
always to be opened. Exceptional cases may occur in which 
the adhesions may be so firmly knit together that they cannot 
be broken unless the sac be opened. Here, as in every operation, 
there is the greatest demand for exact anatomical knowledge, 
for cool and deliberate judgment, for delicacy of manipulation, 



222 



HERNIA. 



and for refraining as much as possible from interference with 
the tissues surrounding our seat of operation. 

The first to employ this operation of dividing the stricture 
without opening the sac was Jean Louis Petit. In his TraiiS 
des Maladies Chirurgicales, published in 1774 as a posthumous 
work, he says he operated in this way more than thirty years 
before. 1750, and goes on to say, "Let us ask ourselves the ques- 
tion, of what use is it to open the sac ? The only purposes that 
I know of are to expose the intestine and omentum in order to 




Via. 49.— Key's Director passed beneath the seat of stricture of a Strangulated Feir.oral Flirjilft, 

outside of the sac beneath the fascia propria. 



remedy morbid changes, if there should be any, to separate these 
parts if they should have become adherent, and to be able to 
handle the intestine, and push back hardened faeces or foreign 
substances. Now I except these cases ; in all others, which are 
far more numerous, why open the sac ? There is no indication 
for such a proceeding ; while, on the other hand, the obvious 
advantages of omitting it are that we avoid exposing the pro- 
truded parts to the air, and escape the risk of wounding them ; 
moreover, I shall show that, in respect to the consequence of 
the operation, it is desirable that the sac should not have been 



KELOTOMY OR HERNIOTOMY. 



223 



opened. From these several considerations I conclude that it 
is hetter to enlarge the ring on the outside than from the inside 
of the sac." In all these arguments he is sustained by Sir 
Astley Cooper, who frequently in practice and in lecture advo- 
cated the method. 

Petit's operation was as follows. Dissecting down to the sac, 
where it passes out from the ring, he insinuated between the 
ring and the sac a flat grooved director curved toward its end. 
A bistoury carried along the groove divided what was thus 
raised. If this division be not sufficient, it may be repeated 
until sufficient space has been made to allow reduction. 








Fig. 50.— Direct Inguinal Hernia. 



"Mr. Key recommends in inguinal hernia a mode of proceed- 
ing by which the surgeon may be enabled to divide the stricture 
either at the internal or external ring. He makes an incision 
of an inch and a half over the neck of the tumour, so as to lay 
bare the lower portion of the external oblique tendon, where it 
forms the ring. A small opening should then be made in the 
tendon just above t the ring : by introducing the director it will 
be found whether the stricture is at the lower or upper opening. 
In the former case the director is carried under the margin of 
the tendon, which is then divided to a sufficient extent. If the 



224 



HERNIA. 



stricture should be at the upper opening, the incision in the 
aponeurosis of the obliquus externus must be enlarged so as to 
expose the lower margin of the two succeeding muscles with 
some fibres of the cremaster. The latter may be separated by 
the end of the director, which should be carried under the end 
of the transversus, the instrument being depressed upon the 
sac in order to carry its point under the border of the muscle, 
which may be divided to the required extent." 

As to the statement which Petit so wisely made in his day, 
that the necessity of opening the sac because of adhesions, &c, 




Fio. 51. — Oblique Inguinal Hernia. 
Bubonocele on right side, but passing through external ring on left. 

was the decided exception to the general rule of cases, Dupuy- 
tren, in 1818, estimated that " six times out of nine strangulation 
is caused by the neck of the sac. Not much later H. Berard 
raised the proportion of eight out of nine, and ultimately Mal- 
gaigne maintained, in 1840, that genu : ne strangulation was 
always caused by the neck, and that the cases of supposed 
strangulation by the rings were cases of inflammation of the 
hernial sac." E. Coulson (Arch-Gen. 1863, I., 273 &c.) in re- 
commending the operation without opening the sac, advises that 
when the hernia is very large, and when the symptoms are more 
those of inflammation or gangrene than strangulation, or when 



KELOTOMY OR HERNIOTOMY. 225 

large adhesions have been formed, the intestine should not be 
reduced, but watched so that the sac may, upon emergency, be 
immediately opened. 



TREATMENT AS GIVEN BY BERNARD AND HUETTE. 

I have found the description of the operations upon strangu- 
lated Hernia, both the taxis and kelotomy, so admirably and 
clearly stated by Claude Bernard and Charles Huette (de 
Montargis) in their Medicine Opiratoire that I have ventured to 
translate it in full. I trust this description will be as interesting 
and instructive to the reader as it has been to me. 

"The operation for the reduction of strangulated Hernia was 
proposed and described for the first time by Franco in 1561. 
Adopted and practised latter by Ambrose Pare\ and perfected 
and described as an operative method by Dionis. 

" The instruments are as follows: — an ordinary straight bistoury, 
a convex bistoury, a probe-pointed bistoury, or Pott's or Cooper's 
herniotomy knife ; (these bistouries have been variously modi- 
fied,) a director, a pair of blunt scissors, and several dissecting 
forceps. Several fine sponges are necessary to soak up the 
blood during the operation ; finally various pieces of dressing, 
lint, compresses, wax, &c. 

" The operator places himself at the right of the patient, having 
assistants at his side and at the left of the patient to hold the 
instruments, to sop up the blood, and to take part in the operation 
as there is need. 

" This operation having for its end the removal of the strangu- 
lation by section of the opening which causes it, is composed of 
several stages, in which successive incisions are made. First, 
the skin. Second, the subcutaneous envelopes of the hernia. 
Third, the hernial sac. Fourth, the constricting ring. Fifth, 
the reduction of the bowels. 

Q 



226 HERNIA. 

" First. — Incision of the SJcin. The incision should be made 
following the great diameter of the tumour, and proportional in 
extent to the volume of the Hernia. It can be made from within 
outwards ; or from without inwards ; when the skin is intimately 
united to the envelopes of the Hernia and cannot be detached by 
wrinkling. In this case it is necessary to make the incision 
with great precaution, and slowly to deepen it little by little. 
The essential point is not to cut the intestine. When the skin 
is soft, adhering but slightly to the deep parts, it is preferable to 
raise a fold of skin from the upper part of the tumour. The 
operator seizes one extremity of this fold, an assistant holding 
the other, and makes an incision from without inwards, or 
better from within outwards by entering the bistoury to its base, 
the edge upwards. 

"This first incision has to do with the skin only, and should 
exceed the tumour in height and depth by a centimetre. It 
is sometimes necessary to make a crucial or T-shaped incision. 

" Afcer the incision of the skin, several small superficial 
arteries give off blood. Before continuing the operation, it is 
well to arrest this slight haemorrhage by torsion and cold lotions. 

" Second. — Incision of the Subcutaneous Envelopes of the 
Sac. — Much precaution and great delicacy of hand is required 
at this step. Some operators cut directly from without inwards, 
holding the bistoury like a fiddle-bow, the edge upon the tumour. 
The surer method is to raise the thin folds which envelope the 
Hernia, with a pair of forceps, and to make a horizontal incision, 
withdrawing each fold by the forceps. Then a director is intro- 
duced at the small opening thus made and pushed under the 
folds to the extremity of the tumour, and the bistoury, with 
its edge upwards, directed by the groove in the director, divides 
the envelopes of the Hernia down to the sac safely and without 
peril. Blunt scissors may also be employed. 

" The number of these envelopes is variable. We have enume- 



KELOTOMY OR HERNIOTOMY. 227 

rated and described theru in treating of the surgical anatomy of 
the inguinal and crural region. 1 But the age of the Hernia, the 
duration of the Hernia, &c, so modify the relations and nature 
of these envelopes that the normal anatomy cannot serve as a 
guide in investigations, and it is often extremely difficult to find 
'the sac in the midst of the abnormal layers produced by the 
hernia. 

" Serous cysts, deposits of fat, gangliotic abscesses, old sacs, &c. 
&c, may obscure the operation, and cause perilous uncertainty 
to the most experienced hand. Several signs are characteristic 
of the sac, viz., a smooth and polished surface, a spherical form, 
a fluctuation caused by an accumulation of lymph, the omentum 
or the intestine seen by transparency, &c. 

" Third. — Incision of Sac. — The sac being found beyond a 
doubt, must be incised with care, in order not to wound the 
intestine. For this a fold of the sac between the circumvolu- 
tions of the intestine, or rather at the level of a portion of the 
omentum, is raised by forceps. This stage of the operation is 
rendered easy in the majority of cases by the lymph which 
bathes and distends the interior of the sac. An incision is 
made close to the forceps so as to make an opening through 
which to introduce the director, guided by which the sac is 
opened through its whole visible length, first above, then below. 
This opening ought to be made as much as possible forward and 
a little outward. It is of importance then to prove that the sac 
is opened. A certain quantity of lymph which escapes after 
the incision, the easiness of exploring the interior of the sac, 
with the director or the finger, when no adherence with the 
intestine exists ; the intestine or the omentum floating freely 
and not adherent except at a point corresponding to the 
abdominal ring ; all these signs together leave no doubt as 
to the nature of the sac which has been opened. Some Hern hie, 
hernia of the ca3cum, for example, have no sac at all. When 

1 See pp. 51, 74. Q 2 



228 HERNIA. 

this particular embarrassment occurs, which is extremely rare, 
it is always easy to recognise the intestines from the structure of 
its investments. In the more ordinary cases the intestine 
appears of a variable colour, according to the duration of the 
strangulation. Its surface is vascular, its colour is a reddish- 
brown more or less deepened, and marked in several places by a 
layer of plastic lymph. The omentum can be easily unfolded 
when it has contracted no adherence. 

"Fourth. — Kelotomy. — Before proceeding to the division of 
the constricting ring, exploration of the neck of the sac should 
be made with the finger, and traction should be carefully made 
upon the intestinal protrusion, in order to effect reduction without 
kelotomy if possible. 

"The situation of the strangulation being well known, and 
kelotomy judged indispensable, the operation can be performed in 
two ways. 

"1. By cutting the constricting ring at the side where one does 
not expect the presence of vessels. 

" 2. By making several incisions at different points over the 
seat of the strangulation ; these multiple incisions extending 
but a short distance, were adopted as a method by M. Vidal 
(de Cassis). 

" Kelotomy is practised with a probe-pointed, straight, convex 
or concave bistoury. The straight probe-pointed bistoury is 
generally preferred, with the blade surrounded by a piece of 
tape, leaving bare only one or two centimetres of the extreme 
edoje of the instrument which ou^ht to be entered under the 
constricting ring. The bistoury may be guided by the index 
finger, or by a director. When the extremity of the finger 
cannot be pushed as far as the obstruction, the director must be 
used; but if the nail can be introduced under the frenum, the 
bistoury can be guided along upon the finger, at first flat then 
raised on edge, and the back of the instrument pushed by the 



KELOTOMY OR HERNIOTOMY. 229 

finger on which it rests, divides the constricting ring. The 
index finger can then be entered still more deeply, and the 
division carried still farther. See Fig. III. 

"Daring the operation, the assistants keep apart the lips of 
the wound and hold back the intestines, which surrounding the 
blade of the instrument, might be wounded and hinder the 
operation. 

" M. Vidal has prepared a grooved spatula to guide the bistoury. 
This director is extremely useful when it is impossible to follow 
the course of the bistoury with the eye. The end of the director 
is first passed between the hernial protrusion, and the part causing 
strangulation. The grooved face is turned upward towards the 
part which is to be divided, and on this face the bistoury is 
pushed forward, with the blade lying flat so that the edge 
cannot act in any way. In division the bistoury is turned upon 
its axis in such a manner as to raise the bistoury on edge, 
scraping as well as cutting the ring. This director protects the 
intestines from the edge of the blade, and keeps them at a 
distance. 

" We have said before that reduction should be tried before 
division is performed, but we must not forget that the location 
of the strangulation is more often at the neck of the sac than at 
the aponeurotic ring. On this account the Hernia may be re- 
duced with the sac, and yet the strangulation may exist at the 
neck after the reduction into the abdomen. It is of importance 
therefore to be well assured of the precise location of the strangu- 
lation, and not to forget that some hernial sacs have multiple 
necks, and that the location of the strangulation may be very 
extended, and reach as far as the superior ring of the inguinal 
canal. Only by feeling and successive divisions can the 
operator discover the difficulties which may complicate the 
operation. 

" There is much difference among authors, concerning the 



230 HERNIA. 

direction and the extent of the division. When the strangu- 
lation is located at the exterior ring, and the neck of the sac can 
be drawn out of the canal, the division is always easy and 
without danger to the epigastric artery. But when the strangu- 
lation is deeper, the impossibility of knowing whether the 
hernia is internal or external, ought to render the operator 
prudent. The division above is less dangerous to the organs 
which ought to be respected. At no part should the incision be 
more than four millimetres, in order to avoid puncturing the 
artery. In the case of external Hernia, the division being from 
without safely admits of a larger incision, which should always 
be proportional to the organs to be reduced. To obtain these 
results it is often preferable to resort to the multiple method 
adapted by M. Vidal. 

" Multiple Division. — When it is necessary to greatly dilate 
the abnormal opening, in order to avoid a too extensive incision, 
causing danger of haemorrhage, M. Vidal proposes to make 
three, four, or a greater number of incisions of two to three 
millimetres. 

" Method of M. Malgaigne. — M. Malgaigne makes the incision 
not in the sac and scrotum, but at the place where the strangu- 
lation appears to be located, prolonging the incision above and 
below to an extent which the obesity of the subject and the 
volume of the Hernia demands. All the tissues are then divided 
as far as the peritoneum, and on this account there is nothing to 
be feared from the vessels which one has under his eyes or puts 
aside at will. If it is discovered that the strangulation is caused 
by a fibrous opening the Hernia is reduced without touching the 
sac. If not, the neck of the sac is divided by short cuts from 
without inwards ; or better, if the stricture is very firm, a small 
incision is made either above or below the neck of the sac, 
which is raised by the director that guides the incision. 

" M. Malgaigne found by this proceeding, before all things, the 



KELOTOMY OR HERNIOTOMY. 231 

advantage of allowing the surgeon to see what he had done ; in 
the second place of reaching the strangulation by the shortest 
road and the least possible incision ; and finally, of respecting 
the scrotum and sac, and avoiding suppuration and cicatrization 
of a wound entirely useless. 

" In support of his method, M. Malgaigne cites a case of very 
voluminous scrotal Hernia. The neck of the sac was located at 
the level of the abdominal ring ; the neck of the sac was opened 
and the sac refilled, the first day with a certain quantity of 
liquid, which was re-absorbed in a measure, when the inflamma- 
tion of the upper wound was allayed. The wound healed 
without accident. 

"Fifth. — Reduction. — In the case of intestinal Hernia, 
when the intestine is healthy, it is necessary to draw it a 
little forward to break up any adherences which may exist, 
when they are weak ; to cause by gentle pressure, the gas which 
fills the intestine to pass into the abdomen, and to return the 
portion of the intestine near the ring portion by portion. If the 
intestines are accompanied by a portion of the omentum, this 
is reduced last. 

" When gangrene has begun' in a portion of the intestine, the 
indications to be followed are various, according to the extent of 
the disease. If any doubt exists as to the existence of gangrene, 
M. Yidal advises that an incision be made with the bistoury, 
upon the diseased intestine, of small extent and very superficial. 
If circulation is active, a large drop of blood immediately forms 
at the small wound ; if on the contrary the intestine is gan- 
grened, the surface of the wound remains dry. In the first case 
the intestine is reduced, in the second not. In case of doubt 
the gangrened portions should be retained at the level cf the 
ring. If there is gangrene, the faecal matter can escape at the 
abdominal opening. 

11 When the intestine is gangrened to a large extent, we must 



232 HERNIA. 

retain the two healthy ends at the ring to facilitate the passage 
of faecal matter at the superior end from the abdominal opening, 
so as to establish an artificial anus which will heal later. It may 
he possible to excise the gangrened parts, and after reuniting the 
healthy parts, to reduce the intestine as a whole. 

" When it is necessary to establish an artificial anus, the 
adherences which unite the end of the intestine to the neck of 
the sac must be gently broken up. The destruction of these 
adherences will allow the intestine to enter the abdomen. If 
the strangulation prevents the faecal matter from escaping 
freely, a speculum may be introduced at the superior end of the 
intestine, and if this introduction is impossible on account of 
the adherences which must be regarded, division should be made, 
with precaution, in front of the sac. 

" Gangrene of the omentum, according to the extent and 
volume of the omentum involved, requires various methods of 
operation. When the gangrened portion is sufficiently extensive, 
the omentum is unplaited, divided at the level of the healthy 
parts, and after the ligature of the vessels, secured at the 
opening of the ring. 

" Crural Hernia. — When the caecum and the superior iliac 
region of the colon are involved by their extra peritoneal part, 
they form a Hernia without a sac. Beyond this exceptional case, 
Crural Hernia is composed almost of the same elements as 
Inguinal Hernia. They are first directed downward in the 
sheath of the femoral vessels, then across the lamina of the 
fascia cribriformis ; then its direction changes, and it remounts 
toward the abdomen under the skin and the layers of the 
subcutaneous tissue. 

"In the majority of cases the neck of the sac is formed at the 
level of the opening of the fascia cribriformis, and here also the 
strangulation takes place, caused by the aponeurotic ring of the 
fascia cribriformis. But when the strangulation takes place at 



KELOTOMY OR HERNIOTOMY. 233 

the superior orifice of the canal, or in the canal, it is always 
the neck which is strangulated. (Malgaigne.) 

"That which we have said of taxis in the case of Inguinal 
Hernia being applicable to Crural Hernia, we will not review it. 
We will only observe that it is necessary for the Hernias to follow 
in a reversed way the sinuosities which they have traversed. 

" Kelotomy. — A simple or reversed T-shaped incision is made 
according to the needs, parallel to the great diameter of the 
tumour. The different tissues which cover the Hernia having 
but little thickness, we must proceed with great precaution, and 
it is often impossible to ( raise a fold of skin from the surface of 
the tumour. The ' fascia propria ' which covers the sac is very 
slight, and may be taken for the sac itself; and some fatty 
collections lining the sac, and seen \>y transparency under the 
fascia propria, may be mistaken for the omentum, and render 
this error easy. It is of importance, then, that the incision 
of the layers which cover the Hernia should be made with 
caution, and division should never be performed from the 
exterior of the sac when the neck of the sac is the cause of 
strangulation. Recent researches of modern surgery have 
caused the older methods of kelotomy to be given up. The 
labors of M. Demeaux have shown that the location of the 
strangulation was at the aponeurotic ring of the fascia cribri- 
formis, and that the neck of the sac never caused strangulation 
of the Hernia. We can therefore with safety make an incision 
from without at the upper part, but below we might meet the 
saphenous vein. If after the division of the aponeurotic ring it 
is proved that the neck of the sac causes the strangulation, we 
can easily draw it forward and divide it. 

" Umbilical Hernia — Kelotomy. — Umbilical Hernia may 
become obstructed or strangulated, and call for the operation 
of kelotomy. 

" We must remember that the envelopes are very fine, and 



234 



HEHNIA. 



that the sac contains but little lymph. These particulars 
render the operation difficult. 

" The operator very carefully makes an incision of a + or 
or T shape. Umbilical Hernia being seldom strangulated at 
the neck of the sac, some authors recommend only a division of 
the fibrous ring without touching the sac, in order not to 
expose the peritoneum to inflammation. This should be fol- 
lowed in the case of large Hernise when it is not necessary to 
lay bare the intestine. 

" A multiple division is preferable to single division, and if 
only a single incision is necessary, it should be directed upwards 
and to the left, in order to avoid the course of the urachus and 
the umbilical vessels." 




FiG.ra.— Operation of Kelotomy. 



To illustrate the operation still further, I would introduce the 
following illustrations from Gay's work on Femoral Hernia, 
published in 1848. The plates were reproduced by Mr. Oxen- 
ham, a pupil of J. D. Cooper, 188 Strand. 



KELOTOMY OR HERNIOTOMY. 



2B5 




Fig. 52. 



The hernial sac mid parts, the subject of this r'rawing. were discovered in the course of a 
dissection. The tumour did not present those external indications that led to a suspicion of 
its existence, i.nti' the superficial and ci ibrifnrm fascia? had been cut through. The engraving 
was made from a cast and drawing of the parts taken by Mr. E. Wilson, and is well 
adapted to show the parts prior to their alterations by the processes of disease. The sac 
is denuded of its fascia propria. Any further description, but for the sake of junior 
students, would be superfluous. 

a a.— Upper layer of the iliac portion of fascia lata. 

6 b.— Pubic portion of the same fascia, or pectineal fascia, forming the floor of the femoral fossa. 

c. — Falciform process, and portion of 1he border of the saphenous opening. 

d. — External or semilunar portion of the same border. 

e.— Burn's ligament, or pubic portion of the arch formed by the lower border of the same 
opening. 

t.— Inferior pillar of the external abdominal ring ; or that portion of the crural arch which 
terminates upon the tuberosity of the pubis and adjoining portion of the ileo-pectineal 
ridge. 

0.— Spermatic cord. 

h. — Saphenous vein. 

i. — Hernial tumour. 

A black line shows the situation and direction of the incision which is made through the 
integuments into the femoral fossa, for the new operation. 



236 



HERNIA. 




Fro. 58. 



Represents a hernial tumour and the adjacent parts of the thigh, as they are displayed by thi 
removal of the superficial fascia and the contents of the femoral fossa. The crura larch 
and upper layer of the iliac portion of the fascia lata have been divided and turned back, 
to show the deep layer of that fascia, and its relations to Hey's ligament The knife is 
passed fimn the femoral fossa behind those scats of stricture, which are here seen. 

a. — The hernia tumour with its cribriform covering. 

bb. — The crural arch divided and turned back. 

c. — Pubic insertion of the tendon of the external oblique muscle. 

d. — Tendon of rectus. 

c— Pubic attachment of the conjoined tendons of the internal oblique and transversal is muscles. 

/.—Portion of Gimbernat's ligament, formed by the outer pillar of the external abdominal ring. 

g. — Portion of Gimbernat's ligament, formed by the falciform process of the fascia lata. 

h. — Situation of the band of fibres belonging to the internal inguinal ligament of Htsselbach. 
below the under layer of the iliac fascia lata. 

i. — The femoral, or Hey's ligament ; or the deep crural arch. 

k. — Upper lamina of the iliac portion of the fascia lata, divided vertically and thrown back, in 
order to display the deep lamina, with Hey's ligament, and its continuity to the arched 
margin of the internal oblique muscle. 

I. — The femoral fossa. 

m.— Process from the deep abdominal fascia which completes the upper arched border of the 
saphenous opening on the pubic side. 




Fig. U. 
a. — The front wall of the femoral sheath, as displayed on the careful removal of the iliac fascia 

lata. 
6, c. — Its iliac and pubic walls. 

d, e,f. — The aiu/les formed by the union of these walls. 
p, h. — The septa by which the sheath is divided, 
t — The upper orifice of the crura canal, or crural ring, 
k. — The venous compartment of the sheath. 
1 1. — Lines showing the direction of the septa of the sheath, — the outer one being between the 

artery and vein. 
m. — The front margin of the loicer orifice of the sheath. 
n. — The crural canal, 
o. — Dotted line, showing the relative position of Hey's ligament to the front wall of the 

sheath. 
p. — The band of fibres appertaining to the front wall of the sheath, described as the "fibra 

crassiores " of the internal inguinal ligament of Hesselbach. 
q— Tendon of the rectus. 
r. — The pubic margin of the crural ring : the septum crural has been pushed before a hernial 

lug, by which the canal has been occupied, 
s.— The terminal portion of the saphenous vein 





Fig. 55. 
The front of the thigh, with a hernial tumour, with dotted lines showing tho situation of the 

crural arch, and the margins of the saphenous ring, 
a. — Edge of process of fascia lata. 

o.— Situation of the spermatic cord. .... ,, . p 

c— A line representing the seat and direction of the external wound for the new method or 

operating. 
The line of incision is represented, as in Fig. 52, in black. 



238 HERNIA. 

author's modification of the operation of kelotomy. 

Before closing the abdominal walls that we have divided in 
our operation with the knife, I would recommend that we apply- 
to the edges of the rings LugoPs solution of iodine, the fluid 
extract of white oak bark, or the following, which I think far 
superior : — 

ft Ext. Quercus Albse, grs. xiL 

Proof Spirit, gj. 

Morp. Sulph. grs. iv. 

Sulph. Ether, 3iv. 
M. 

This mixture is to be applied with a long soft camel's hair 
brush, or by means of a bit of absorbent cotton, and will cause 
an effusion of lymph over the wounded parts, which effusion 
will consolidate the rings with new tissue not unlike the results 
of our operation on reducible Hernia by subcutaneous injection. 
Whether by this means we obtain a cure or not, we shall at 
least do no harm from our simple application, and may dispense 
with the succeeding subcutaneous injection. 

Dr. Derby, of Vermont, has succeeded in effecting a cure in a 
strangulated Hernia by means of the application of iodine, 
which I have mentioned. 

In case we use iodine, or the preparation of oak bark I have 
given, I would advise that we apply no moisture on our com- 
press for the first twenty- four hours. Powdered ice in a bladder, 
or rubber bag, would be preferable as an application if inflam- 
mation sets in or is feared ; in fact I think very highly of such 
an application as a constant dressing in all cases of inflam- 
mation after any surgical operation of any importance over the 
abdominal region. 



KELOTOMY OR HERNIOTOMY. 



239 



NEW HEBNIOTOMY KNIFE. 

In place of the ordinary Herniotomy knife I have adopted an 
instrument devised by myself, and here figured. 1 

In shape it is like a bistoury of the ordinary form, as made 
by Milliken of London. Instead of a cutting blade, I have 
adapted to it the narrow saw used by Dr. George F. Shrady, 
surgeon to the Presbyterian Hospital of New York. This saw 
can be withdrawn into the hollow shaft of the instrument, 
which can then be used as an ordinary groove director. When 
it has been introduced beneath the ligament to be cut, this 
saw can be pushed forward and used to make our necessary 
incision. 




F:o 66.— This is a probe-pointed bistoury, having the ecige A fc serrated and protected by a 
sliding rod c which keeps it from cutting during its introduction, but is withdrawn when 
the desired region is reached. 



We shall, by this means, serrate the ligament instead of 
cutting it smoothly, and shall avoid, or at least lessen, the 
danger of severing the epigastric, or obturator arteries, or 
branches from them. 

The ligaments being roughened will consolidate under the 
effusions of lymph much more readily than they would if the 
cut had been smooth ; and the arteries, should they happen to be 
injured or severed, will from their lacerated edges contract like 
the edges of a lacerated wound with very little haemorrhage and 
danger to the patient. Such minute details, if we would meet 
success, should always be as faithfully attended to as the major 
and seemingly more important steps in the operation. To illus- 
trate the safety of these operations where the ligature of 
arteries is not so indispensable as once was thought, I insert the 

1 See p. 377. 



240 HERNIA. 

following quotations upon surgical operations without ligatures, 
from one of my communications to the Boston Medical and 
Surgical Journal. This only brings to our notice the old and 
well known fact of the contractility of lacerated vessels when 
severed by sawing or tearing them asunder. 

In 1872, Mrs. , of Kittery, Maine, aged about thirty- 
eight, of light, sanguine complexion, mother of two children, 
had. a tumour of the left breast about the size of a duck's egg, 
which began soon after the cessation of lactation with her last 
child. This tumour made its appearance on the inner side of the 
left breast just below the nipple, which felt hard and doughy to 
the touch. The nipple was retracted, and there was a deep, 
dark areola around it. Her suffering was so great that she was 
unable to sleep, and it had occasioned a general loss of appetite 
and strength. 

She was placed under the influence of ether, and the usual 
elliptical incisions were made. In so doing branches of the in- 
ferior mammary artery were laid bare, and traction was made 
upon them, previous to their general division with a saw-like 
movement of the bistoury. Eetraction of these arteries took 
place, completely closing them against any haemorrhage. Some 
slight hemorrhage from smaller vessels was controlled by 
torsion. The parts were now brought together without the use 
of any ligatures. The wound was closed with five silver 
sutures and adhesive plaster, and healed almost entirely by first 
intention. 

In the fall of 1878 a young girl from Attleboro', aged fifteen 
or sixteen, received an injury by a stone thrown against her 
breast, where a hard swelling arose and developed into a cystic 
adenocele. The whole breast became much enlarged, swollen, 
and painful just above the nipple. The tumour and the hard 
swelling continuing to grow in spite of treatment, it was de- 
cided to amputate the breast. Being called to perform the 



KELOTOMY OR HERNIOTOMY. 241 

operation, I proceeded after etherisation to remove the greater 
portion of the breast by making semi-elliptical incisions, keeping 
the vessels well on the stretch. Her attending physician wrote 
me that the entire wound healed by the first intention, or at the 
primary dressing without any suppuration. This patient being 
young and in vigorous health, well nourished, and with breasts 
enormously large, the circulation was very free, and the tendency 
to haemorrhage much greater than in the first case, where con- 
tinued suffering had caused a reduction in the vital forces, and 
at the same time enfeebled the circulation. 

This operation shows the contractile power of the muscular 
coats of the arteries when traction is made on them before 
their division. To illustrate still further how much can be done 
in many operations without the use of ligatures by taking 
advantage of this contractile power of the arteries, I will relate 
the following case : — 

Mrs. H., of Concord, Mass., aged sixty-eight, on November 7, 
1878, consulted me for a large fatty, bell-shaped, fibroid tumour 
which grew from the gluteus maximus, was suspended by a 
pedicle of about two and a half inches in diameter, and extended 
nearly to her knee on the left side. It had existed over 
twenty-five years, and a portion of the inferior part had sloughed 
obliquely off, leaving a large ulcerated surface which was dis- 
charging a very offensive fluid. The constant weight — about 
three pounds — had caused a prolapsus uteri, together with a 
partial prolapsus of the anus and bladder. This tumour, from 
its discharge and the burden of carrying it, as the patient was 
very slight in stature, — was very weakening and enfeebling. 

On the 12th of November, after etherisation, I operated on 
the tumour, with the assistance of Dr. M. E. Webb, of Boston, 
by making two longitudinal elliptical incisions as close as con- 
venient to the pedicle, and removing all the attachments except 
where the arteries ramified into the substance of the tumour. 



242 HERNIA. 

These arteries were very large, and accompanied by a vein fully 
equal in size. Before the final division of the vessels I made 
retraction, placing them greatly on the stretch, and then pro- 
ceeded slowly to divide them with a saw-like motion, as related 
above. Full contraction and closure of the arteries took place. 
The wound was now brought together, and coaptation effected 
by silver sutures and Dr. Martin's United States army adhesive 
plaster. It healed almost entirely from the first dressing, ex- 
cepting a small portion, about three quarters of an inch of the 
lower part of the incision, which was designedly left open for 
drainage, and so kept by a few threads of coarse saddler's silk. 
The patient in two weeks was able to return home perfectly 
healed, with her prolapsed organs restored to their natural con- 
ditions, the uterus being supported with a Hodge's hard rubber 
pessary. She was ordered to take quinine and iron, and when 
she visited me in the winter she had gained so much flesh and 
strength that she considered herself comparatively young again. 
Neither in major nor minor operations have I had secondary 
haemorrhage by this method so frequently as when T have been 
obliged to resort to ligatures, and I have had better success in 
the healing, since the parts so brought together have generally 
united by first intention. My attention was called to this con- 
tractility of the arteries from the fact that in early life I noticed 
that in many lacerated wounds we have but little haemor- 
rhage where we should have supposed from the size of the 
arteries that there would be much, and that such wounds, when 
proper coaptation could be had, — when freed from dust and oil, 
— would generally heal by first intention ; but where ligatures, 
even though small, were used in fresh wounds, suppuration took, 
place almost invariably. 



CHAPTER X. 

Eecent Operations for Hernia. 

Since the appearance of the first edition of this work, the 
following new operations have been made public. In order to 
present them fairly, I have given them in full detail. 

Immediate Care of Inguinal Hernia by a netv Instrument. — 
By the courteous permission of W. Dunnett Spanton, M.E.C.S., 
Surgeon to North Staffordshire Infirmary, England, I reprint 
from the British Medical Journal of December 11, 25, 1880, 
and January 8, 1881, the following essay : — 

When we consider for a moment the enormous number of 
cases of hernia met with in practice, — those applying to the 
truss societies of London alone, numbering over nine thousand a 
year, — it seems strange that so little comparatively has been 
accomplished in attempting to cure such cases permanently. 
Most surgeons seem to rest contented with some palliative 
measure, which, sooner or later, is tolerably certain to be found 
wanting at the critical moment, when strangulation is about to 
take place. The ancients were in their generation somewhat 
wiser ; for, fifteen hundred years ago, the operation for radical 
cure was comparatively common ; and long before that (about 
B. c. 400), Hippocrates described the operation, which, for aught 
we know, may have been practised even before his time. 

The different methods which have been practised for the 



244 HERNIA. 

immediate or radical cure of hernia may be roughly classed 
under four heads, viz., 1. Contraction of skin and sac by ex- 
cision, cautery, or ligature ; 2. Closure of the sac by adhesive 
inflammation ; 3. Plugging the inguinal canal ; 4. Bringing the 
walls of the canal together. 

1. Among the old surgeons, the first method was the only one 
employed. Celsus says that, in his day, the surgeon opened the 
sac with a sharp instrument, took hold of it, and, after putting 
back the intestine, cut the sac, then tied the spermatic cord and 
removed the testicle. He then took away part of the scrotum, 
and reunited the lips of the wound, so as to form a firm 
cicatrix. 

Paulus iEgineta followed Celsus, but ligatured the sac before 
cutting it, and sometimes applied the actual cautery also ; and 
in cases of bubonocele, he advocated cautery alone, applied to 
the skin sufficiently to penetrate the parts beneath, — " being 
guided as to its extent," he says, " by a skilful conjecture." 

Oil of vitriol used as a caustic, by being repeatedly applied 
over the inguinal ring until it penetrated all the soft tissues, 
was in vogue in the early part of last century, and was as bar- 
barous as it was ineffectual. 

Another plan, invented by Berault, was styled the punctum 
aureivm. See page 102. The rupture was reduced, the sac laid 
open, taken hold of with pincers, and a gold wire passed through 
it, which was then twisted and cut off. Other kinds of wire 
were subsequently employed by other surgeons. At the best, 
this operation could only convert a complete into an incomplete 
hernia; but it appears seldom to have effected even so much. 
About this period, a much more barbarous modification of this 
operation was in vogue among the Turks, which is fully described 
in Arnaud's work. 

2. Of the second series, the best example is that of the seton. 
Various substances have been employed with the object of set- 



OBSERVATIONS AND OPERATIONS. 245 

ting up inflammatory action in the interior of the sac, so as to 
cause the sides to adhere, and so prevent protrusion of the bowel. 
Silk thread, sponge, injection of irritant fluids of various kinds, 
were at different times employed for the purpose by various 
surgeons. The method, by whatever variety of practice carried 
out, appears to have been even less efficacious than the barbarous 
practice of the ancients, and, almost, if not quite, as dangerous. 

3. In the third class, Wurtzer's operation affords the best 
illustration ; that of Gerdy being very similar. See pages 104 
and 106. In the latter, the skin of the scrotum, with the fundus 
of the sac, is invaginatecl by the finger of the operator into the 
inguinal canal, and a curved needle armed with thread is passed 
through the skin of the groin on each side of the finger, and the 
skin retained in its place by means of the suture until it becomes 
adherent. Sometimes caustic ammonia was used, in order more 
certainly to obtain union between the two invaginated skin- 
surfaces. Wurtzer used instead of the finger a wooden plug, 
retained in situ by means of needles passed through the skin at 
its extremity, and fixed externally to a corresponding piece of 
wood, so placed as to produce sufficient compression of the inter- 
vening tissues as to secure their adhesion to each other. The 
records of successes after these measures are, I believe, compara- 
tively few ; and I have myself seen some instances in which the 
rupture has been made seriously worse by Wurtzer's operation. 

4. The fourth plan differs materially from the foregoing, in 
providing the remedy which Sir W. Lawrence pointed out as 
being required to contract the tendinous opening {Treatise on 
Ruptures, by W. Lawrence, 1816, p. 94). The idea of bringing 
together the pillars of the inguinal ring in such a way as to 
restore the normal valve-like shape, is based on true anatomical 
principles, and to Mr. John Wood must be ascribed the great 
credit of having reduced these to valuable practical results. See 
page 108 of the present work. Wood's operation, however, con- 



246 HERNIA. 

sists not merely in approximating the pillars of the ring, but in 
the subcutaneous invagination of the tissues which are intended 
to fill up the abnormally expanded opening. Stress is laid by 
Mr. Wood on the fact that, " to ensure success, complete union 
must be established along the whole length of the canal " (On 
Rupture, by John Wood, p. 88). This statement first led me to 
consider how far it might be feasible to secure such a result with 
greater simplicity and certainty. In using the wire sutures of 
Mr. Wood, as ordinarily applied, a hold is secured on the pillars 
of the ring at two points only, while the invaginated tissues are 
forcibly drawn up in such a way as, in some measure, to defeat 
the object the surgeon has in view, of approximating the sides 
of the canal as much as possible. By means of the operation I 
propose, you will see that these drawbacks are overcome. (Fig. 
57.) The points of security are multiplied, and the invaginated 
plug, being rather cylindrical than conical, is retained in position 
in such a way as to permit the walls of the canal to come as 
close together as possible. The instruments required are very 
simple, — a thin strong knife, like a tenotomy knife, for separat- 
ing the skin from the subjacent tissues ; and the screw instru- 
ment (Fig. 58.) shaped like a corkscrew, with a flat point and 
movable handle, nickel-plated. The screw is made rather broader 
near the point, tapering somewhat towards the handle, and should 
be sufficiently strong not to break, but yet as thin as may be 
consistent with strength. The instruments in box are repre- 
sented in Fig. 59. 

The mode of performing the operation in a case of ordinary 
oblique inguinal hernia is as follows. The patient must be in 
good health, have an aperient the clay before, and an enema on 
the morning of operation. If necessary the pubes must be 
shaved. Under the influence of an anaesthetic the hernia is 
carefully reduced, and not allowed to come down during the 
operation. An incision is made in the skin of the scrotum large 



OBSERVATIONS AND OPERATIONS. 



247 



enough to admit the forefinger easily, over the fundus of the 
hernial sac, generally about two inches below the spine of the 




Fig 57. 




Fig. 58. 




Fig. 60. 



Fig. 61. 




os pubis ; and the skin is separated from the parts beneath by 
means of the blade or handle of a narrow scalpel, to an extent 
determined by the size of the hernia, and that of the inguinal 



248 HERNIA; 

canal. The operator standing on the left hand side of the 
patient, the forefinger of the left hand is passed up to the in- 
ternal abdominal ring, invaginating the fascia and hernial sac to 
the same extent. A careful examination is now made of the 
surrounding structures, the position of the vessels clearly made 
out, the size and shape of the abdominal rings noted, as well as 
the length of the canal. This is necessary, in order to have an 
instrument of the proper size. The left forefinger being retained 
in the hernial canal, protecting the spermatic cord, and at the 
same time closing the internal ring, the screw instrument, pre- 
viously dipped in carbolic acid, is, with the right hand, thrust 
through the skin of the groin so as to transfix the aponeurosis 
of the external oblique muscle, at a point somewhat above that 
at which it is intended to pass through the conjoined tendon. 
(Fig. 60.) Having given the instrument one half turn to the 
right if a right inguinal, and a whole turn if it be a left hernia, 
it is next made to pierce subcutaneously the conjoined tendon 
of the internal oblique and transversalis muscles as high up 
as can safely be reached, the left forefinger carefully guarding 
the point so as to avoid wounding the vessels or peritoneum. 
This part of the operation must be executed cautiously and 
deliberately. It will be then found that as soon as a hold has 
been secured by the instruments the internal ring is practically 
closed. Another turn is now given to the screw, causing it 
to pass through the invaginated tissue — whether consisting of 
fascia or sac, or both — and it is again passed through the ex- 
ternal pillar, and then across to the internal pillar of the external 
ring, and another turn given if possible, so as to bring the point 
out at the wound in the scrotum. The handle should then lie 
flatwise on the abdomen, and the point of the instrument be 
protected by a round piece of solid India-rubber, or by winding- 
round it some carbolized gauze. (Fig. 61.) A light pad is then 
placed over the part, and a bandage carefully applied. 



OBSERVATIONS AND OPERATIONS. 249 

The operation may be performed under Lister's antiseptic 
method, as in two of the cases (IV. and VII.) I have to record ; 
but it is well then to leave the instrument in situ rather longer. 
The results are equally satisfactory if this precaution be observed, 
and there is, of course, less danger from any septic influence. 

The subsequent treatment is very simple. After a period 
varying from a week to a fortnight, a certain amount of inflam- 
matory action will be observed along the line of the inguinal 
canal where the instrument lies, and more or less discharge 
takes place from the wounds. The amount of induration ex- 
cited will be the guide as to the time for removal of the in- 
strument ; but a week has been usually found sufficient. The 
removal of the instrument is easily effected, as the suppuration 
which takes place along its course serves to loosen it somewhat; 
and, by keeping it well oiled from day to day, it is easily with- 
drawn. The wounds will readily heal under any simple dress- 
ing, with pad and bandage. A truss may be worn for a time, as 
the adhesions will of necessity not be very firm at first ; but, in 
most of the cases I have operated on, this has been dispensed 
with without any ill results. 

The aim of the operation is to bring together the pillars of 
the hernial canal, and at the same time to plug the opening in 
such a manner as to shut it off from the peritoneal cavity on 
the one hand, and, on the other, to form an impassable barrier 
against any further descent of the bowel. So long as the gen- 
eral peritoneal cavity is not interfered with, so far is danger 
averted ; and if the hernial canal be effectually closed through- 
out, so to the like extent is the cure complete. 

The operation is simplicity itself to any one accustomed to 
operative surgery ; and with regard to the danger attending it, I 
can only say that it has now been performed by myself and my 
colleagues in thirteen cases, in not one of which has any serious 
symptom been observed, the highest temperature recorded being 



250 HERNIA. 

101.2° Fahr. ; and, in eleven of the cases, the cure has been com- 
plete ; in the remaining two the patients have been greatly bene- 
fited. I think, therefore, I am justified in saying that it is a 
simple, a safe, and a very efficient method of curing suitable 
cases of hernia. 

I append a record of all the cases in which the operation has 
been performed up to the time of writing this paper. 

Appendix of Cases. 

Case I. Right Oblique Inguinal Hernia. — W. H., aged eigh- 
teen, a farmer's son, living in Shropshire, working on the farm, 
was seen at Hanley on December 12th, 1877. He was a healthy, 
muscular lad, had always enjoyed excellent health, but for about 
a year had been the subject of right oblique inguinal hernia. I 
saw him in consequence of strangulation of the hernia, caused 
by lifting some heavy baskets from a market-cart. After fomen- 
tations and a dose of opium, the hernia was reduced by taxis ; 
and, keeping him quiet until December 5th (four days after), I 
performed the operation for radical cure, in the manner already 
described. The rupture was small, and the opening of the in- 
ternal ring was small also. Ether was administered by Mr. W. 
A. Frost, who assisted me, and the operation was performed 
without any difficulty. He suffered no pain worth mentioning, 
and had no constitutional symptoms. No medicine of any kind 
was given until on the third day a dose of castor-oil ; after which 
time the bowels acted naturally. On the tenth day the instru- 
ment was removed, both of the openings in the skin at that time 
discharging a little pus, and the scrotum and testis of the same 
side being swollen. There was a firm band of adhesion along 
the whole line of the inguinal canal. The wounds quickly healed 
under the application of terebene oil, and a hard thickened plug 
remained, completely closing the hernial opening, so that no 



OBSERVATIONS AND OPERATIONS. 251 

impulse could be felt on coughing. He wore a truss for better 
security. I saw him about two months afterwards, when the 
adhesions remained quite firm. About six months afterwards, 
he felt so secure that he gave up wearing the truss ; and during 
some violent exertion in the hay-field, there was a partial giving 
way of the adhesions, with a tendency to a return of the hernia. 
He has since that time worn a truss, and had no further trouble. 
In this case I think I was rather too timid, and failed to take as 
secure a hold of the abdominal rings as I ought to have done ; 
but, as a test-case, the result was so far a source of satisfaction 
to me, inasmuch as it showed that the operation could be carried 
out without a symptom to cause any uneasiness. 

Case II. Congenital Hernia in a Child. — T. B., aged four 
years, was healthy and strong, and had a right congenital rup- 
ture. On admission into the North Staffordshire Infirmary, on 
October 2d, 1878, there was a large scrotal hernia of the size of 
a large duck's egg, and two fingers could be easily passed through 
the hernial opening. He had worn a truss for some time, but it 
was quite impossible to keep up the hernia, and it would even 
force down under the pressure of the fingers. On October 7th, 
1878, chloroform being administered, I operated, some of my 
infirmary colleagues being present. In this case, there being no 
proper sac, the scrotal fascia and tunica vaginalis formed the 
invaginated plug ; and it is noteworthy that, with the free com- 
munication with the general peritoneal cavity which existed, 
there was no sign whatever of peritoneal irritation. The child 
suffered from chloroform-sickness for some hours, but afterwards 
progressed most favorably. He made no complaint of pain ex- 
cept when disturbed, and no constitutional symptoms showed 
themselves. Considerable oedema of the scrotum followed ; and, 
on October 13th (six days after operation), there was free sup- 
puration from both the openings. The instrument was removed 
under chloroform. A hard thickened mass of tissue occupied 



252 HERNIA. 

the inguinal canal, and, on straining or coughing, no impulse 
could be felt. On the 18th the wounds were quite healed, and 
the child was in perfect health. The opening .was securely 
closed, and remains so. 

Case III. Right Oblique Inguinal Hernia. — A. S., a warehouse- 
man, aged fifteen, was admitted into the North Staffordshire 
Infirmary, under my care, on October 29th, 1878. Three weeks 
before admission, while lifting a weight, he first noticed the 
hernia. There was a small right inguinal hernia, which had 
never been strangulated. The general health was good. After 
the usual preparation, I operated under ether on November 9th. 
Considerable pain was complained of after the operation, which 
was at once relieved by loosening the bandage, and the adminis- 
tration of a hypodermic dose of morphia. He had no sickness. 
On November 12th there was considerable oedema of the scro- 
tum, and some purulent discharge from the wounds, especially 
the lower one. He slept well, and the general health re- 
mained good. On November 18th he complained of some ab- 
dominal pain on the right side, with tenderness in the right 
inguinal and iliac regions. There was a slight erysipelatous 
blush in the same neighborhood, with moderate discharge of 
pus. The temperature rose for the first time to 101.2° Fahr. 
After an enema the bowels acted ; the instrument was re- 
moved, and a warm water pad applied, with immediate relief. 
From this date the pain, swelling, and discharge gradually sub- 
sided, so that, nineteen clays after operation, he was able to be 
shown to a meeting of the Staffordshire Branch of the British 
Medical Association. He left the hospital about a fortnight 
afterwards, when the occlusion of the inguinal canal was so 
complete that no truss seemed to be needed. In this instance 
much more irritation was set up than in either of the preceding 
ones. The result showed, however, that it was purely local ; 
and this, of course, within certain limits, is likely to prove bene- 
ficial rather than injurious in its ultimate effects. 



OBSERVATIONS AND OPERATIONS. 253 

Case IV. Left Inguinal Hernia. — Annie B., aged nine, living 
at Stoke, was admitted, under my care, into the infirmary, on 
December 7th, 1878. She was a ruddy, healthy-looking, plump 
girl. Her mother stated that while playing, about a year pre- 
viously, the hernia appeared. It was readily reduced on lying 
down, was about the size of a small hen's egg, and had never 
been strangulated. The hernial opening admitted one's finger 
easily. With the ordinary preparations, the operation was per- 
formed on January 1st, 1879, under chloroform, and with strict 
antiseptic precautions under carbolic spray. Carbolized gauze 
w T as used to protect the point of the instrument. The tempera- 
ture never rose beyond 99° Fahr. There was an entire absence 
of sickness or other constitutional disturbance. On January 4th 
the bowels acted naturally. On the 8th the instrument was 
removed (the temperature rising on that day, affording us a good 
indication for doing so). There was some induration along the 
track of the screw, and a few drops of pus at each opening. On 
January 13th the wound was again dressed under spray. There 
was very slight discharge ; a firm cord was felt along the line of 
the inguinal canal. There was no tendency to any protrusion. 
On January 16th the antiseptic dressings were left off. The 
wounds were quite healed, and firm. She was kept in bed a 
few days, and a pad and bandage applied. She left the hospital 
ten days afterwards, perfectly well, and not requiring a truss. 
She has continued sound up to the present time. 

Case V. Right Oblique Inguinal Hernia. — S. T., aged eleven, 
a schoolboy, was admitted into the infirmary, under the care of 
my colleague, Mr. Folker, on January 7th, 1879. Six months 
before admission the hernia was caused by a strain. The tumor 
was small, the internal ring easily admitting the point of the 
finger. On January 11th the operation was performed under 
chloroform. On the 14th there had been no complaint of pain ; 
the discharge was slight, and the temperature and pulse normal. 



254 HERNIA. 

On the 17th there was some oedema of the scrotum, and in- 
creased discharge, with slight pain. Castor-oil was ordered. On 
the 18th the instrument was removed, some little difficulty being 
encountered in taking the gauze off the point. On the 26th he 
was allowed to get up, with a pad and bandage applied. The 
inguinal opening was firmly closed by a hard band, and there 
was not the slightest impulse to be felt. On February 10th he 
left the hospital cured. The boy came to the infirmary three 
weeks afterwards to show a " lump " which had appeared where 
the hernia had been. This was found to be fluid — an artificial 
hydrocele of the cord, in fact — which was conclusive in showing 
not only that the internal ring was closed, but the external 
opening effectually closed also. The fluid has since gradually 
become absorbed, and there exists now only a fibrous cord along 
the track of the inguinal canal. 

Case VL Right Congenital Inguinal Hernia. — ; W. B., aged 
three, was admitted, under the care of Mr. Folker, on April 1st, 
1879. The internal ring easily admitted the index finger. The 
left ring was closed, and both testes had descended. Operation 
having been delayed in order to improve the child's general 
health, was performed on May 10th, under chloroform. The next 
day, the little fellow wanted to get up ; he had no pain, and 
was only annoyed at the confinement. At night he became 
feverish, and had some abdominal pain, with retention of urine, 
requiring the use of the catheter. On May 12th there was no 
pain nor further retention. On May 17th the discharge was 
profuse. The instrument was removed, the opening being com^ 
pletely occluded. On June 2d he was allowed to get up ; no 
pad or truss being needed, as there was no tendency whatever 
to a return of the hernia. He left the infirmary on June 5th, 
quite well, and has remained so. 

Case VII. Large Right Inguinal Hernia. — T. K., aged 
twenty-six, a potter, was admitted, under my. care, on April 



OBSERVATIONS AND OPERATIONS. 255 

28th, 1879. The patient had a large right inguinal hernia, 
which had existed about two years ; and he was suffering also 
from nodular scrofulous disease in each testicle, the right one 
being as large as a goose egg. His general health being unsatis- 
factory, cod-liver oil and iodide of iron were ordered, with Scott's 
dressing to the testis. On June 7th, his condition being much 
improved, and the size of the testes diminished, the operation 
was performed under carbolic spray, chloroform being given. 
The hernial sac was thick, and very adherent to the surrounding 
tissues ; but invagination was effected without much difficulty, 
the inguinal canal being open enough to admit two fingers. 
Next day (June 8th) he was free from pain ; no sickness ; tem- 
perature, 99° Fahr. On June 9th the dressings were changed. 
The wounds were quite quiet; temperature, 98.4° Fahr. On 
June 11th he was again dressed; temperature, 99.4° Fahr. On 
the 14th there was very slight suppuration from each opening ; 
temperature, 98° Fahr. On June 16th the instrument w T as 
removed easily ; there was free suppuration from both openings. 
His general condition was good. The bowels acted sponta- 
neously. The patient was restless and fidgety, so that the 
dressings were disturbed rather frequently. The temperature 
yesterday was 100° Fahr.; to-day, 99.8° Fahr. On the 19th 
the upper wound was closed ; there was very slight suppuration. 
A firm cord could be felt along the line of the inguinal canal, 
which was securely closed. The swelling of the testis was 
greatly diminished. (Incidentally,, this is an interesting fact, 
and is probably explained by the blood supply being diminished 
from pressure on the vessels of the spermatic cord.) On July 3d 
he was allowed to get up and walk, a pad and bandage being 
applied. The temperature varied, the highest record being 100° 
Fahr., until June 23d, when it was normal. On July 10th the 
wounds were firmly closed; there was no impulse on coughing. 
He was discharged cured. He has reported himself since, keep- 
ing quite sound, but wearing for security a light pad-truss. 



256 HERNIA. 

Case VIII. Right Inguinal Oblique Hernia. — George W., 
agjed eicrht, was admitted, under the care of Mr. Folker, on June 
12th, 1879. The hernia was about the size of a hen's egg, the 
hernial opening easily admitting the index finger. On June 21st 
the operation was performed under chloroform. After the oper- 
ation vomiting occurred, and he complained of some pain, which 
was relieved by an opiate. On June 23d the dressings were 
changed. There was no discharge. The patient was rather rest- 
less, but slept well. On June 26th the scrotum was red and 
swollen. There was slight discharge, and rather more pain. On 
June 30th the instrument was removed. The discharge was 
profuse, and the scrotum still cedematous. On July 5th (four- 
teen days from operation) the discharge had ceased ; the wounds 
were rapidly healing ; the swelling was subsiding. On July 9th 
the wounds were healed; no discharge. The swelling was gone. 
There was no impulse on coughing, On July 16th. the patient 
was quite well, and the wounds quite sound. A few days after- 
wards the hernia showed a tendency to return behind the cord ; 
the anterior part of the inguinal canal remaining firmly closed. 

Case IX. Congenital Right Inguinal Hernia. — L. E., aged 
three, a healthy little fellow, was admitted, under the care of 
Mr. Folker, on June 24th, 1879. After the usual preliminary 
preparation, he was operated on June 28th, under chloroform. 
On the 29th the temperature was 99° Fahr. ; on the 30th, 98.4° 
Fahr. July 1st. He had been very "good" since the operation, 
not requiring any opiate, nor any special attention. Temperature, 
100.2° Fahr. On July 4th castor-oil was given, which acted 
twice, causing no pain. The discharge was more free. Tem- 
perature, 100.2° Fahr. On July 6th, under chloroform, the 
instrument was removed ; the India-rubber covering the point 
being much more easily managed than the gauze used in the 
previous cases. Temperature, 100° Fahr. On July 9th the dis- 
charge was much less. All swelling and irritation had subsided. 



OBSERVATIONS AND OPERATIONS. 257 

The bowels acted daily. On July 14th there was no discharge. 
He was allowed to get up. The openings were quite firmly 
occluded. 

Case X. Right Inguinal Hernia. — Wm. J. T., aged nine, was 
admitted, under the care of Mr. Folker, on July 17th, 1879. No 
cause was assigned for the rupture, which was first noticed about 
a year before. It was of the ordinary oblique kind, and about the 
size of a hen's egg, reaching into the scrotum. On July 19th, 
after the usual preparation, the operation was performed under 
chloroform. Much sickness followed, and considerable straining. 
Temperature, 98.2° Fahr. On July 20th there was no complaint 
of pain ; no sickness. Temperature, 99° Fahr. On July 26th 
(seventh day) the instrument was removed. There was some 
discharge from, both openings, but less than in some of the 
previous cases. An enema was ordered, as castor-oil, previously 
given, had been inoperative. The temperature was 99° Fahr. ; 
it had been on the 25th 99.8° Fahr. On July 28th there was 
little discharge, and no surrounding irritation. The patient felt 
"quite well." On July 31st the line of the canal was hard and 
dense, and appeared most effectually closed. There was no 
impulse on coughing. 

Case XL Left Inguinal Hernia. — Wm. Jas. D., aged thirteen, 
was admitted on July 17th, 1879. About two years previously 
the rupture was occasioned by lifting a very heavy weight, and 
was now about the size of a hen's egg. On July 2 2d the opera- 
tion was performed, after the usual preliminaries, under chloro- 
form. In this case a steel instrument was used. On July 23d 
there was no sickness, but he complained of some slight pain. 
Temperature, 99° Fahr. On July 26th the discharge was rather 
free, and surrounding irritation was more marked than in most 
cases, — due, possibly, to the employment of a steel instead of 
a plated instrument, but also in some degree to the fact that the 
point of the screw pressed rather firmly on the scrotum. It 



258 HERNIA. 

would have been better, perhaps, if another turn had been made 
in the operation, so as to place the point beyond the skin of the 
scrotum. On July 28th the discharge was more profuse. The 
temperature yesterday was 99.4° Fahr. ; to-day, 98.4° Fahr. On 




Fig. 62. — From a photograph taken three days after operation. 

July 28th the patient was rather feverish. The temperature had 
risen to 101.4° Fahr. The instrument was removed quite easily, 
the India-rubber slipping off very readily. On July 31st he was 
quite comfortable. The discharge was slight. He had no pain. 
Temperature, 99.4° Fahr. A firm, hard swelling was felt along 
the spermatic canal, and there was no impulse whatever on 
couojhinsr 

Case XII. Right Oblique Inguinal Hernia. — John B., aged 
eleven, was admitted to the Staffordshire Industrial School, under 
my care, on July 25th, 1879. The cause of the hernia was un- 
known; but the rupture was first observed about two years 
before, and was about the size of a small orange. No truss 
had been worn. On July 26th, after the usual preparation, the 
operation was performed under chloroform. (Fig. 62.) On July 
28th he complained but little of pain, though an irritable sub- 
ject. There was slight purulent discharge, and some oedema of 



OBSERVATIONS AND OPERATIONS. 259 

tlie scrotum. "Temperature, 100.4° Fahr. There had been no 
sickness since the operation. He had a rather troublesome 
cough (which he had had some time) ; but there was no ten- 
dency to any reappearance of the hernia. He was ordered 
some linctus, to be taken frequently. On July 29th the tem- 
perature was 100° Fahr. ; on the 30th 98.6° Fahr. On July 
31st the line of the inguinal canal was quite hard and firm, 
the instrument still in. The temperature was normal. On 
August ,4th the instrument was removed. The hernial canal 
was firmly occluded. He was discharged well on September 
27th. He has been working on a farm since, and remains 
quite well. 

Case XIII. Right Inguinal Hernia. — Elizabeth W., aged 
twenty, a domestic servant, a healthy, strong, young woman, was 
admitted into the North Staffordshire Infirmary, under the care 
of Mr. Alcock, on July 15th, 1879. When lifting a heavy 
weight, she noticed a swelling suddenly appear in the right 
groin, which, on admission, was found to be a hernia about 
the size of a hen's egg, which disappeared in the recumbent 
posture. On July 31st, the operation was performed under 
ether, No. 2 screw being used. She progressed without any 
unfavorable symptom. The instrument was removed on Au- 
gust 8th, the opening being firmly plugged. She left the Infir- 
mary on September 18th, quite sound. 

Case XIV. Bight Oblique Inguinal Hernia. — Mrs. S., married, 
aged twenty-seven, residing at Hanley, a stout, w r ell-developed, 
healthy woman, had only one child, ten years previously. She 
never had any serious illness. She first noticed rupture eight 
years ago, after falling down some steps. It had gradually in- 
creased in size, and latterly became painful. When I saw her on 
September 23d, 1879, there was a right oblique inguinal hernia, 
about the size of a duck's egg, and the inguinal ring was quite 
open. After preliminary preparation, I operated at the patient's 



260 HERNIA. 

house on October 7th, 1879, Dr. Partington administering chlo- 
roform. Lister's aDtiseptic dressings were used, and the operation 
was performed under carbolic spray. After the operation, some 
chloroform-sickness ensued, which soon subsided. — October 8th. 
She slept little, but had no pain. There was frequent retching. 
Temperature, 98.5° Fahr. ; pulse, 96. — October 9th. She slept 
well after a dose of morphia. The wound was quiet. Temper- 
ature, 98.5° Fahr. She had no pain. — October 10th. She was 
going on well. The wound was dressed under spray. There 
was slight serous discharge, and some oedema along the inguinal 
canal, with induration. She was ordered to have a dose of 
castor-oil. The daily progress was uninterruptedly good, and 
she suffered no pain. — October 15th. The wound was dressed, 
and the instrument removed There was very little discharge ; 
the track of the instrument was indurated throughout. — Oc- 
tober 23d. The antiseptic dressings were removed. The wound 
was almost healed. Simple dressing and a pad and bandage 
were applied. — October 26th. The wounds were quite healed. 
She was allowed to get up. There was no impulse in the 
inguinal canal on coughing. — November 14th. She had been 
about ordinary household duties, and felt quite comfortable, and 
could stoop and move without any pain or discomfort such as 
she had previously. She wore a pad truss, and has continued 
well and strong since. 

Case XV. Bight Inguinal Congenital Hernia. — Frederick J., 
aged four, was admitted into Children's Ward, North Stafford- 
shire Infirmary, under Mr. Spantou, on August 23d, 1879. He 
was a healthy, unmanageable child, with a large scrotal hernia 
of the size of a man's closed fist. The inguinal rings were very 
wide, and the finger could be passed easily within the abdomen. 
No truss was of any avail to keep up the rupture. On Au- 
gust 23d, after the usual preliminary treatment, I performed the 
operation with the screw instrument, under chloroform. Owing 



OBSERVATIONS AND OPERATIONS. 26i 

to the great width of the pillars of the hernial ring, I could not 
satisfactorily secure a hold upon the internal pillar, which was, 
indeed, so far obliterated that it was formed chiefly by the bor- 
der of the rectus-sheath. I had some misgiving a t the time 
that the hold I had obtained was not sufficiently secure, and the 
sequel shows that this was well founded. — August 24th. The 
patient had during the night removed the lint pad and also the 
ball from the point of the screw. The latter was not replaced, 
but the bandage was firmly reapplied. — August 28th. The 
patient was very restless, although he said he had no pain. 
The instrument had become twisted somewhat, owing to his 
constant movement. He took food well. — August 30th. A 
slight attack of diarrhoea came on. — August 31st. The instru- 
ment was removed (eight days after operation), — there being a 
moderate amount of irritation in its track and slight purulent 
discharge. The temperature had never risen above 98° Fahr. 
'September 5th. The hernia had descended again, and the in- 
guinal ring was almost as patent as before operation. The 
child appeared quite well. — September 30th. He was allowed 
to get up. It was found impossible, even with a firm pad, to 
keep up the rupture. Feeling convinced that the failure was 
due to an imperfect hold having been obtained on the internal 
pillar of the hernial canal, quite as much as to the unruly 
behavior of the patient, I decided to operate again ; and on 
October 10th, under chloroform, I performed the operation a 
second time, taking especial care to obtain as firm a hold as 
possible of both sides of the inguinal canal. This involved 
taking up the sheath of the rectus ; and I found that the adhe- 
sion of the subcutaneous tissues to the skin of the scrotum 
rendered the separation of them more troublesome than usual. 
But the operation was satisfactorily completed in the ordinary 
manner. — October 12th. He slept well; had no pain. He was 
much less restless than after the former operation. Tempera- 



262 HERNIA. 

ture, 98.6° Fahr. — October 13th. There was some oedema of 
the scrotum; no discharge. — October 21st. He progressed well. 
The highest temperature had been 99.6° Fahr. (on 13th) ; since 
then normal. There was a considerable amount of local irrita- 
tion along the course of the instrument, and a moderate purulent 
discharge. The instrument was removed under chloroform. — 
October 24th. The wounds were healing rapidly ; the discharge 
had ceased. This morning, while dressing, the child cried lus- 
tily; but there was no tendency to any descent of the bowel. 
The canal was occupied by a firm fibrous mass, and completely 
occluded. — December 8th. He was allowed to get up, wearing 
a pad-truss ; and on the 19th he was discharged well. 

Case XVI. Plight Oblique Inguinal Hernia, — Thomas P., 
aged twenty, glass-cutter, single, was admitted into the North 
Staffordshire Infirmary, on August 29th, 1879. The rupture 
was about the size of a hen's egg, of three months' standing 
caused by jumping. On August 30th, the operation was per- 
formed in the usual manner, under chloroform. — September 3d. 
There was slight discharge from the lower wound. The gen- 
eral condition was good. — September 6th. The instrument was 
removed ; the ball being imbedded under the skin, owing to the 
screw being rather too short. — September 10th. The discharge 
had ceased ; the wounds were nearly healed. There was a firm 
cord along the inguinal canal, which gave no impulse on cough- 
ing. — September 15th. He was allowed to get up. The 
wounds were quite healed ; the plug firm. — September 22d. 
He was discharged well. — September 29th. He called to report 
himself as feeling quite sound, and not needing a truss. 

Case XVII. Bight Congenital Inguinal Hernia. — Albert O, 
aged six, was admitted into the Infirmary on September 11th, 
1879, under Mr. Alcock. Before admission, the hernia was 
strangulated, and great difficulty was experienced in its reduc- 
tion. On admission, a rupture of the size of a small egg was 






OBSERVATIONS AND OPERATIONS. 263 

present, quite reducible. On September 13th, the operation was 
performed under chloroform, after the usual preparation. — Sep- 
tember 14th. He suffered but little pain, slept well, and seemed 
comfortable. — September 20th. The instrument was removed 
under chloroform. — September 24th. The wounds were nearl} 
healed ; the discharge was slight. There was some swelling of 
the scrotum. No impulse was produced on coughing. — Octo- 
tober 9th he was allowed to be up. The hernial canal was 
obliterated, and there was no impulse on coughing. He was 
discharged cured. The highest temperature in this case was 
99° Fahr. 

Case XYIII. Right Inguinal Congenital Hernia. — William 
C, aged five, was admitted into the Infirmary on September 
30th, 1879. The child, on admission, did not appear strong. He 
had a right congenital hernia of the size of a large hen-egg. 
The pillars of both rings could be clearly defined, and the open- 
ings easily admitted one's finger. Cod-liver oil and iodide of iron 
were ordered for a few days ; and on October 11th, after the 
usual preparation, the operation was performed by Mr. Folker, 
under chloroform. — October 12th. He slept well; no pain. 
Temperature, 98.4° Fahr. — October 20th. The instrument was 
removed. Some difficulty was experienced in taking away the 
ball from the point of the screw, owing to its being buried in 
the tissues. Temperature, 100° Fahr. — October 23d. A hard, 
rather painful enlargement was felt on the right side of the 
scrotum. There was free purulent discharge. Temperature, 
101.4° Fahr. He was ordered to take some bromide of potassium 
mixture, and have evaporating lotion applied. The swelling 
gradually subsided ; and on October 30th, the temperature was 
normal. He was allowed to be up on December 7th. The 
swelling was quite gone ; the inguinal canal firmly occluded ; no 
tendency whatever to recurrence of hernia. He wore a pad- 
truss. — December 11th. He went home quite well. 



264 HERNIA. 

Case XIX. Right Inguinal Hernia. — Mary F., aged twenty- 
six, milliner, was admitted under my care on November 14th, 
1879. The patient, fairly healthy, but not robust, had been sub- 
ject to hernia for about seven years', for which no cause could be 
assigned. It had never been strangulated, but was often painful ; 
and, although a truss to some extent would keep it up, yet it 
often would come down, and cause inconvenience. As she was 
engaged to be married, and anxious to have something done to 
effect a permanent cure, my friend Dr. Orton of Newcastle asked 
me to see her with a view to operation. There was a right in- 
guinal oblique rupture of the size of a duck's egg ; the hernial 
opening being large, easily admitting the finger. After the usual 
preparation, I performed my operation on November 17th, under 
chloroform. An incision was made in the right labium majus. 
The skin was separated subcutaneously for an extent of about 
three quarters of an inch in every direction; and the fascia and 
hernial coverings made to plug the canal in precisely the same 
manner as already described, the difference being that in this 
case it was less easy to separate sufficient tissue to form an effi- 
cient plug. In introducing the screw, I was careful to obtain as 
firm a hold as possible at two points in each pillar of the canal, 
and to bring it up close, inasmuch as there was not the same 
necessity for avoiding constriction as in the case of men, where 
the spermatic cord has to be carefully considered. Lister's spray 
and dressings were employed; but we found. that, owing to the 
position of the wound, it was almost impossible to carry out 
the system satisfactorily. — November 19th. Since the opera- 
tion, she had had pain in the epigastrum. Poultices and an opiate 
gave relief. The dressings were changed. There was no dis- 
charge ; a slight blush around the wound. Temperature, 99.2° 
Fahr. ; pulse, 84. — November 21st. The dressings were re- 
newed. Serous discharge and inflammation were slight. Tem- 
perature, 99° Fahr. She was ordered a dose of castor-oil. — 






OBSERVATIONS AND OPERATIONS. 265 

November 24th. The parts were dressed again under spray. 
There was slight discharge ; the wound gaped a little. Tem- 
perature 98.8° Fahr. An enema was given, after which the epi- 
gastric pain was relieved. — November 26th. The instrument 
was removed under chloroform (ninth day) ; discharge slight, 
purulent. — December 10th. The discharge had been more abun- 
dant, coming from the track of the instrument. She felt quite 
well. Poultices were applied. — December 14th. There was 
less discharge ; the wound was healing. She had no nain, but 
some tenderness to touch along the inguinal canal. — Decern- 
ber 27th. Simple dressing was applied. The wound was nearly 
healed ; the canal seemed securely closed ; no impulse on 
coughing. — January 1st. She was allowed to get up, wearing 
a pad-truss. The patient has since married, and has had no 
tendency to any return of the rupture up to this time (No- 
vember, 1880). 

Case XX. Right Inguinal Oblique Hernia. — Fred. D., aged 
six, was admitted into the infirmary, under my care, on Novem- 
ber 18th, 1879. The patient was healthy, and the rupture was 
first noticed six months previously. On admission, both testes 
were down ; there was a large oblique inguinal right hernia of 
the size of a small orange. The tissues were very lax, and the 
rings large. On November 22d, I operated, under chloroform, in 
the usual manner, without experiencing any difficulty. At the 
same time, the prepuce was divided, to relieve phimosis, which 
existed. — November 23d. He slept well; had very little pain; 
no sickness, Temperature, 99° Fahr. — November 26th. Con- 
siderable inflammatory oedema of the scrotum had appeared. 
There was very slight discharge from wounds. The bowels 
acted spontaneously. Temperature, 100° Fahr. — November 
29th. The instrument was removed under chloroform. Dis- 
charge free ; the swelling of the scrotum continued. Tem- 
perature, 101° Fahr., indicating the need for removing the 



236 HERNIA. 

instrument. — December 12th. The wounds were quite healed. 
The temperature fell to normal after November 29th, and re- 
mained so. — December 29th. He was allowed to get up, wear- 
ing a pad-truss, which he bore quite well. — On January 8th, 
1880, he went home; the inguinal canal being firmly occluded, 
with no tendency whatever to any return of the rupture. . 

Case XXI. Left Congenital Inguinal Hernia. — John C, aged 
seven, was admitted into the Infirmary, under the care of Mr. 
Folker, on November 11th, 1879. He was rather a delicate- 
looking boy, in whom the rupture had come very gradually. 
On admission, there was a left inguinal rupture, which de- 
scended to the size of a hen's egg, with very patent ring. — 
November 15th. The operation was performed by Mr. Folker, 
after the usual preliminaries, under chloroform. — November 
1 6th. He had had no pain nor vomiting ; he was very quiet. 
Temperature, 99° Fahr. — November 17th. The wounds were 
dressed; the parts were quiet. Temperature, 99° Fahr. — No- 
vember 19th. He had a troublesome cough. Slight discharge. 
He complained of pains in the legs (from lying so still ?). 
Temperature, 98°. — November 24th. The instrument was re- 
moved under chloroform. The discharge was rather profuse ; 
but the surrounding irritation was less than in some cases where 
the screw was removed earlier. Temperature, 100° Fahr. — 
December 12th. The wounds were quite healed. He wore lint 
pad and bandage. — December 19th. He was allowed to get up, 
with a pad-truss. The parts were quite firm, without any ten- 
dency to return of the rupture. — December 2 2d. He went home 
quite well. 

Case XXII. Eight Inguinal Hernia from Application of 
Sayre's Jacket. — Elizabeth M., aged five, was admitted into the 
Infirmary, under Mr. Folker, on December 18th, 1879. The 
child was admitted for angular curvature of the spine, and had a 
Sayre's Jacket applied in the ordinary way. Very shortly after- 



OBSERVATIONS AND OPERATIONS. 267 

wards, she was found to have a right inguinal rupture coming 
down as large as an egg, and easily reduced. On January 10th, 
1880, the hernia was operated upon with the screw instrument, 
under chloroform. — January 11th. She had an opiate last night, 
and was quite easy to-day. Temperature, 98.6° Fahr. — January 
17th. The instrument was removed easily. There was consider- 
able irritation around the wounds. Temperature, 98.4° Fahr. — 
January 2 2d. The wounds were still discharging. There was a 
good plug of thickened tissue in the hernial canal. — February 
2d. Over the track of the screw, a small abscess formed, which 
broke this morning. She had a bad cough. She continued to 
improve ; but, on March 15th, for the first time, there was no- 
ticed a tendency to a return of the hernia at the internal ring 
when she cried or coughed much, but at no other time. She left 
the Infirmary wearing a pad. The chief point of interest in 
this case is the unusual cause for the hernia (see page 28) ; and 
this was probably the reason, moreover, why the operation was 
not perfectly successful. If it had been deferred until the 
child's health had improved and her cough relieved, it is quite 
possible that the result would have been more perfect. But even 
as it is, a pad sufficiently controls what tendency to bubonocele 
exists and will gradually complete the cure, in all probability. 

Case XXIII. Bight Oblique Inguinal Hernia. — Daniel A., 
aged twenty-five, miner, was admitted into the Infirmary, under 
Mr. Alcock, on January 6th, 1880. Four years previously, the 
rupture was caused by lifting a weight. At first, only a bubo- 
nocele existed, until three weeks before admission, when the her- 
nia descended to the extent of two inches below the external 
ring and was easily reducible. He had been wearing a truss, 
but this failed to keep up the bowel. On January 10th, the op- 
eration was performed under ether. The tissues were very loose, 
and invagination was easy. After the operation he had much 
pain, requiring opiates. Evening temperature, 99.8° Fahr. — 



268 HERNIA. 

January 12th. The right half of the scrotum was cedematous, 
and the skin somewhat inflamed. The ball came off the point 
of the screw, but was not replaced. He complained of consid- 
erable pain and thirst. An opiate at night and soda-water were 
ordered. Temperature, 101° Fahr. — January 14th. The scro- 
tum was much inflamed and swollen. Castor-oil was ordered. 
Temperature, 101.4° Fahr. — January 16th. The bowels acted 
after an enema. The swelling and the inflammation of the scro- 
turn were increased ; the discharge profuse. Temperature 102.4° 
Fahr. The instrument was removed. — January 21st. The dis- 
charge was still profuse. The inflammation of the scrotum was 
subsiding. He had but little pain, and felt much better. Tem- 
perature, 98.2° Fahr. Some matter formed on the outer and 
upper part of the scrotum, which was opened on February 1st, 
and washed out with carbolic-acid lotion. From this time 
he gradually improved ; and on March 1st, the wounds were 
quite healed. A firm mass of tissue occupied the lower part of 
the hernial canal ; but the hernia could be felt slightly to enter 
the internal abdominal ring, and then was stopped by the 
plugged canal. He left the Infirmary on March 15 th, wearing 
a pad-truss. In this case it would appear that an insufficient 
hold was obtained on the pillars of the internal ring ; or it may 
possibly be that the excessive suppuration which occurred tended 
to loosen the early adhesion which was set up, and allow the 
invaginated tissues to slide, as it were, from their first secure 
position. As it is, the patient is much better for the operation. 

For the two following cases I am indebted to Mr. Jabez 
Thomas, Surgeon to the Swansea Hospital. 

Case XXIV. Left Congenital Hernia. — Charles E., aged 
eleven, was admitted into Swansea Hospital, under Mr. Thomas, 
on December 26th, 1879. "The operation was carried out in 
all its details on January 12th, under the carbolic spray, and 
the whole instruments and wounds covered with a pad of gauze, 



OBSERVATIONS AND OPERATIONS. 269 

secured by a bandage. The patient vomited once during the 
night, and the following morning complained of pain and ten- 
derness over the' lower part of the abdomen ; no tympanites. 
Temperature, a.m., 102°; P.M., 100.4°. Liquor morphia? (tt\.x) 
relieved him, and the next day this had disappeared. — January 
14th. Temperature, A. M., 102° ; p. M„ 100.4°. As the gauze was 
saturated with blood and serous oozing, the parts w r ere dressed 
under spray. Looked well ; tender ; no redness ; a little oedema 
of scrotum, and orchitis. — January 19th. The temperature 
gradually went down, until it reached normal on this day. The 
wound was dressed as before ; slight suppuration ; induration 
along canal well marked. Soap and water enema caused good 
evacuation, the patient feeling no pain or inconvenience. The 
left testis was still swollen. — January 23d. The screw was 
removed ; there was no suppuration ; the wound was dressed 
as before. There was good induration along the course of the 
inguinal canal. The bowels acted naturally. — January 26th. 
The bowels have continued to act daily naturally. — January 
28th. The dressings were removed. The wounds were healed. 
The canal was occupied by a good firm elongated plug, to ichich no 
impulse vms imparted on coughing. — February 12th. He was 
discharged cured." 

Case XXV. — Mr. Thomas writes : " The second case, in a 
child nine years and a half old, ran a similar course to the first, 
with equally good results." ..." I saw my first case a few 
days ago, and found the inguinal canal quite obliterated ; and 
there was no impulse imparted to the induration which occupies 
its sites." 

It would be difficult, I think, to adduce stronger testimony 
than this of the practicability and efficiency of the operation. 

In the same journal for March 19, 1881, a modification of the 
operation is suggested, but Mr. Span ton writes me that he finds 
" the original plan the best : the screw retained in situ causes 



270 HERNIA. 

less irritation and a better permanent result than a catgut liga- 
ture. Some of my earlier cases were performed more than three 
years ago, and I see them frequently. They remain perfectly 
sound." The suggestion is to use a hollow spiral to carry a 
thread, which should be allowed to remain in situ. Mr. Span- 
ton, at the above date, says, however : — 

" When I had the privilege of giving a demonstration of my 
operation at the Cork Northern Hospital, during the meeting of 
the British Medical Association in that city, I showed a screw- 
needle made on this very principle, but not hollow. It is a very 
difficult matter to pass a thread through a hollow needle with 
several curves ; I therefore employed a screw such as I ordinarily 
use for the operation, but having an eye near the point large 
enough to carry silk or catgut. The plan I then advised was to 
pass the screw in the ordinary way, and then thread it ; and, on 
withdrawing the screw, to allow the ligature to remain in situ, 
each end of it being secured to a piece of wood or other smooth 
material, such as glass or porcelain, in order to keep it on the 
stretch while the parts are thus held in apposition. I have used 
it in a case of hernia in a boy this week ; but my fear is, that 
there may not be sufficient irritation set up to cause the in- 
vaginated tissue to become agglutinated. But we shall see. 
Hitherto, I have been so well satisfied with the results after 
using the screw itself, that I have been unwilling to adopt the 
alternative plan, which is, after all, similar in effect to Mr. John 
Wood's operation by ligature." 

ANTISEPTIC METHODS. 

Antiseptic Ligature of Neck of Sac. — In the Edinburgh 
Medical Journal for December, 1880, Thomas Annandale, Eegius 
Professor of Clinical Surgery in the University of Edinburgh, 
published the following : — 

It is scarcely necessary to remark that operative treatment 



OBSERVATIONS AND OPERATIONS. 271 

for the obliteration or removal of the sac, with the hope of 
causing the radical cure of hernia, is no new proceeding. 

The various methods from time to time suggested and prac- 
tised for this purpose do not now possess the confidence of 
surgeons — (1) because the risk of such operations is not 
slight ; (2) because the results obtained are rarely satisfactory. 

Owing to the employment of catgut as a subcutaneous ligature 
or suture, and the introduction of the Listerian antiseptic treat- 
ment of wounds, attention has, within the last few years, again 
been directed to operative procedures on the hernial sac ; and 
since Mr. Lister, in his address to the British Medical Associa- 
tion at Plymouth, in August, 1871, related his experience of two 
most interesting cases which he had treated with these aids, 
many patients have been operated upon according to his prin- 
ciples. 

Dr. Isidor Iraelsohn has recently published his most interest- 
ing dissertation on this subject, and in it he has collected 
seventy-one cases of the radical operation for hernia performed 
with antiseptic precautions by various surgeons. My house- 
surgeon, Dr. Waters, has kindly analyzed the list of these cases, 
and I learn from him that sixty-six of these operations were 
successful, the result of one was not given, and four patients 
died. It further appears that, of the sixty-six, fifty-eight re- 
mained free from return of the hernia at varying intervals after 
the operation, and in eight the hernia returned sooner or later, 
but in some of these cases only to a slight extent. 

As far as I know, four methods have been employed with the 
aid of Listerian antiseptics. 

(1.) Ligature of the neck of the sac alone. 

(2.) Ligature of the neck of the sac, with invagination of the 
ligatured sac into the abdominal opening. 

(3.) Ligature of the neck of the sac, and excision of the sac 
below the ligature. 



272 HERNIA. 

(4.) Ligature of the neck of the sac, with excision of the sac, 
and stitching together the margins of the abdominal opening. 

Having used all these methods, I have no hesitation, from my 
experience, in giving preference to the fourth plan. 

The operation, then, which I practise, is to expose the neck 
and upper portion of the sac by a line incision, to make a small 
opening into the sac, to carefully return the contents, and, in the 
case of adherent omentum or intestine, to ligature and divide 
adhesions, to separate the sac from its attachments to surround- 
ing textures, to draw down the sac and apply a catgut ligature 
around its ueck as high np as possible, to cut away the sac 
immediately below the ligature, and then to stitch together with 
a continuous catgut suture the margins of the abdominal open- 
ing, the stump of the ligatured neck, and the surrounding cellular 
tissue. The whole operation and the after treatment are per- 
formed under strict Listerian principles. 

I will now refer to the classes of cases in which the operation 
may be used. 

(1.) In cases of strangulated hernia : 

Jan., 1872, I operated upon Mrs. M., set. 70, for strangulated 
femoral hernia. On opening the sac a knuckle of congested gut 
was found, and a large piece of omentum, the latter being firmly 
adherent to the sac. Having divided the stricture, I ligatured 
the omentum with catgut, cut it across, and returned the intes- 
tine and ligatured stump of omentum into the abdomen. I then 
separated the sac from the surrounding textures, drew it down, 
and having applied a catgut ligature around its neck, cut away 
the sac and adherent omentum. The result pleased me so much 
that since then it has been my practice, in all cases of strangu- 
lated hernia in which the gut was in a proper state to be 
returned, and in which a distinct sac existed, to adojit this 
proceeding ; but I have, in addition, stitched the margins of the 
abdominal opening together. In illustration I relate the follow- 
ing case : — 



OBSERVATIONS AND OPERATIONS... 273 

Miss L., aet. 32. She had suffered from an irreducible femoral 
hernia for three years, and on the morning of the day I visited 
her, she was seized with symptoms of strangulation shortly after 
straining herself in lifting some heavy books. The usual opera- 
tion for strangulated hernia was performed, and on opening the 
sac it was found to contain a large knuckle of gut and a portion 
of adherent omentum. Having divided the stricture and liga- 
tured and cut across the omentum, the gut was returned, the 
neck of the sac ligatured, the sac and adherent omentum cut 
away, and the stump of the ligatured sac carefully stitched to 
Poupart's ligament and to the surrounding tissues. She is able 
to go about with perfect comfort, but wears a light truss as a 
matter of precaution. 

(2.) In permanently irreducible hernia. 

The operation advocated in this paper is perhaps of more 
value in this class of case than in any other, and I offer a few 
cases in illustration. 

Case 1. — Mrs. C, set. 50, May 24, 1880, suffering from a large 
irreducible femoral hernia the size of an infant's head. A 
swelling was first noticed in the region of the hernia five years 
before her admission, and until eighteen montphs ago was re- 
ducible. Since then it has been irreducible, and during the last 
few months has given her so much inconvenience that she 
required to lie almost constantly on her back. One week after 
her admission the operation already described was performed, 
and as a large mass of omentum was adherent to the sac it was 
ligatured and cut away. She was dismissed cured and wearing 
a light truss on the 14th of June. 

I am no advocate for operative interference in cases of re- 
ducible hernia, unless the condition is irrelievable by the applica- 
tion of a truss or other means, and is giving rise to serious 
inconvenience. When operative treatment is required in these 
cases, I am inclined to advise the adoption of the proceeding of 
winch this paper treats. 



274 HERNIA. 

This proceeding has certainly the one important advantage 
that the surgeon sees what he is doing, and I have not found 
that the free exposure and handling of the parts is attended 
with any special risk. Mr. Charles Steele, of Bristol, deserves 
the credit, as far as I can ascertain, of having been the first to 
treat a reducible hernia on the antiseptic principles. 

Czemy's " Radical Cure." — As a further contribution to the 
antiseptic method of operating upon hernia, the following paper 
by Dr. H. Braun, Professor and Assistant Physician at the 
Surgical Clinic at Heidelberg, is extracted from the Berlin klin. 
Wochenschr. No, 4, 1881 : — 

While the repeated publication, during the last few years, of 
radical operations for the cure of hernia, has arrived only at 
establishing the harmlessness of such operations, the time has 
now come for the communication of the final results. This has 
already been done in isolated instances by Mass and Socin — 
for the purpose of deciding whether, and to what extent, the 
expectations excited by these various novel operative methods 
have been realized. 

The following communication, which is partly intended as a 
contribution to the literature of the radical operations for hernia, 
but partly and especially destined to aid in judging of the final 
results, is restricted to the consideration of nineteen operations 
in various forms of hernia, which were performed on sixteen 
patients in the Surgical Clinic at Heidelberg, under strictly en- 
forced antiseptic precautions. The histories of the five patients 
first operated on were reported three years ago by Dr. Czerny in 
his contribution to operative surgery ; those of the eleven who 
were operated on later are given below. 

Case I. — H. Hirsch, of Heidelberg, two aud one-half years 
of age, admitted October 21st, 1877, on account of an incarcer- 
ated left inguinal hernia which had been first noticed eight 
days after his birth, but had only been partially relieved by a 



OBSERVATIONS AND OPERATIONS. 275 

truss. The symptoms of strangulation had made their appear- 
ance on the day previous to his admission. After enemata of 
large quantities of fluids and attempts at reduction by the taxis, 
while in the bath and during narcosis, had all been attended by 
no success, my colleague, Dr. Kaiser, on October 21st, performed 
external herniotomy, whereupon the reposition of the intestines 
was easily accomplished. The orifice of the hernial sac was 
closed by means of two sutures of well-disinfected silk. We 
did not deem it advisable to ligate the sac, as its loosening was 
not sufficiently practicable on account of its thin texture. The 
inguinal canal was so considerably narrowed by the suture that 
it hardly admitted the introduction of the tip of the little finger. 
A drainage-tube was placed in the cavity of the wound, and the 
integument over it was united by means of the button suture. 
During the first few days after the operation the scrotum swelled 
and appeared inflamed, and until October 27th there was an 
elevated temperature ; patient had a stool for the first time on 
October 22d, after a small enema of water. Suppuration from 
the wound was scanty, and the treatment was aseptic throughout. 
A small abscess in the scrotum was opened on October 30th, 
and on November 5th, at the eighth change of the dressings, the 
healing of the wound and abscess was found to be complete, so 
that on the 10th the child was discharged. The orifice of the 
hernial sac seemed to be completely closed, and the sac itself 
had shrivelled to a thin string ; no infiltration could be discovered 
in the scrotum. 

After being discharged, the child wore a truss for three weeks, 
after which it was left off entirely. The intestine, however, 
never appeared through the inguinal canal again, and the cure 
was complete. At an examination in September, 1879, as well 
as on a subsequent one in August, 1880, the inguinal canal was 
found passable for the tip of the little finger, but even in cough- 
ing no noticeable impulse was felt and no other hernia had 
formed at any other place. 



276 . HERNIA. 

Case II. — A. Wolf, aged six and a half months, of Heidelberg, 
had acquired in the twentieth week after birth a left inguinal 
hernia, which could be held back easily by means of a truss. 
According to the statement of the physician in attendance, who 
brought the child to the Clinic, April 18th, 1878, on account 
of symptoms of incarceration — vomiting, constipation, and 
hardening of the hernia — the taxis had been successfully 
performed four weeks previously, on the appearance of similar 
symptoms. 

Upon the admission of the little patient, the vas deferens 
could be plainly distinguished, and immediately before it could 
be felt a solid swelling, the thickness of the little finger, which 
could positively not be diminished in size, even during narcosis. 
As the symptoms of incarceration remained unchanged, on the 
evening of April 18th I performed herniotomy, exposing a her- 
nial sac of extraordinary thickness and filled with serous fluid ; 
its inner surface was reddened, but it contained no intestinal 
loop. We had evidently to deal with an inflamed hernial sac, 
which had caused the symptoms of strangulation. The sac was 
partly ligated at its neck with catgut, as its complete loosening 
from the vas deferens could not be effected, a drain was put into 
the wound and Lister's dressing applied. During the following 
night the bowels moved twice, but the vomiting did not again 
occur. On April 19th, however, strong convulsions of the 
extremities appeared, which recurred, always with increasing 
violence during the night and on the 20th. The wound remained 
entirely aseptic, scarcely any secretion forming. On April 20th, 
at 5.30 p.m., the patient died in very violent general convulsions. 
At the autopsy the wound was found to be agglutinated, with 
no trace of suppuration ; no traces of peritonitis were discovered 
and the brain showed no pathological alteration. 

Case III. — E. Bidlingmaier, aged forty-three, of Hockenheim, 
was admitted into the hospital on May 7th, 1878, suffering from 



OBSERVATIONS AND OPERATIONS. 277 

a strangulated right femoral hernia,* and on the same day 
herniotomy was performed ; after resection of a piece of intes- 
tine (?) the loop was easily returned to the abdominal cavity. 
The neck of the hernial sac was ligated with thick silk. The 
wound healed without interruption, and on June 17th the 
patient was discharged, wearing a truss. The time required for 
complete recovery of the hernia itself could not be accurately 
ascertained, as the patient did not show himself for some time. 
On examination in September, 1879, it was noticed that a small 
hernia had again appeared. In June, 1880, the condition was 
unchanged and the hernia had not increased in size. 

Case IV. — M. Schultheiss, aged forty-five, of Handschuch- 
sheim, had worn a truss, as well as he could recollect, since his 
fifteenth year, on account of a right inguinal hernia. In the 
fall of 1877, in lifting a heavy load, he brought on a left rupture 
also, which of late had been gaining in proportions. He was 
admitted on June 7th, 1878, as on account of the large size of 
the two ruptures they could no longer be retained by means of 
trusses. The scrotum measured on the right side, from the ex- 
ternal inguinal opening, 23 ctm. ; on the left side, 24 ctm. ; the 
circumference of the scrotum at its base was 39 ctm. Prof. 
Czerny performed the radical operation. The right hernial sac 
was lioated with silk, its orifice closed with five button-sutures 
of carbolized silk ; the sac was opened, its cavity washed out 
with a five per cent carbol-solution, a drainage tube was placed 
in the scrotum, and the integument united by means of button- 
sutures. After this, the orifice of the sac on the left side was 
closed with four silk sutures, and the remainder of the operation 
conducted as in the right side. During the few days following 
the operation, an ice-bag was kept upon the Lister dressing, the 
patient was kept upon a liquid diet, and morphia was adminis- 
tered several times subcutaneously. 

* The history of this case was published in extenso by Prof. Czerny in the 
Berlin Tclin. Wochcnschr. No. 38, 1880. ' 



278 HERNIA. 

On June 9th the dressing was changed for the first time, the 
bands having given way, as the restless patient would not re- 
main quiet for a single moment. On the right side the upper 
part of the wound was somewhat swollen and reddened, while 
on the left side the wound was entirely without reaction ; some 
sutures were removed at this dressing. On June 11th the swell- 
ing and congestion had extended alone; the crest of the right 
ilium ; slight suppuration appeared along the stitches of this 
side, while, as in the preceding case, the wound of the left side 
showed no reaction ; all but three of the sutures were removed. 
On June 12th, there were for the first time abundant stools. On 
the 13th the swelling on the crest of the ilium was smaller, but 
on the other hand, the right half of the scrotum was more 
swollen and the testicle itself exceedingly sensitive to touch. 
On the left side, the last stitches were removed, the wound was 
completely healed and in the future remained closed. During 
the next few days the suppuration on the right side continued. 
From June 23d a dressing of oiled wadding was applied on 
account of the appearance of a carbolic eczema. 

On June 26th and for several following days, some pieces of 
the now gangrenous hernial sac came away, two of the sutures 
at the orifice of the sac appearing in the suppuration. The 
swelling of the surrounding tissues yielded gradually. The 
temperature was always normal except on the seventh and 
eighth days, when it rose to 38.5° and 38.3° C. By the 16th 
of July the wound had closed completely. On the 26th the 
patient could leave, entirely cured, wearing a truss and a sus- 
pensory bandage. On the right side a slight impulse could be 
felt on coughing, but on the left nothing could be noticed. It 
was impossible to ascertain accurately the length of time re- 
quired for a complete cure in this case, as the patient wore the 
truss very irregularly. At a subsequent examination on Nov. 
10th, 1879, a hernia scrotalis was found to have developed on 



OBSERVATIONS AND OPERATIONS. 279 

the right side ; the orifice was large enough to give passage to 
the intestine. On the left side the hernia descended to the 
root of the penis and was about the size of a hen's egg ; the 
orifice admitted the passage of a finger-tip. Both hernias could 
be easily reduced, and retained by means of a truss. During 
the fall of 1880 the orifices of the hernial sacs had become more 
dilated and the rupture had increased in size, but could be 
entirely retained by the truss, which, however, the patient wore 
very irregularly. 

Case V. — M. Marx, aged forty-five years, of Schriesheim, has 
for two years had a left inguinal hernia, which, until about three 
months ago, was about the size of a hen's egg, when it suddenly 
became larger. On his admission, July 30th, 1878, the tumor 
was 21 ctm. in length, measuring at the base 38 ctm., while its 
largest circumference was 42 ctm. Eeduction of the rupture 
was difficult, and to retain it completely was no less so. Walk- 
ing or working caused such severe pain within the hernia that 
the patient urgently asked that the operation might be per- 
formed, which was done by Prof. Czerny on August 2d, 1878, 
in the presence of Prof. Billroth. The sac, which was consid- 
erably thickened, was incised and, after the intestine it con- 
tained had been shoved back into the peritoneal cavity, was 
tied up above with a thick silk thread, its orifice closed with 
four similar silk sutures, and the wound, into which several 
sutures were placed, was washed out with a five per cent 
carbol-solution, drainage applied, and the whole covered with 
antiseptic gauze. 

The day after the operation it became necessary to change 
the dressings, as they were saturated with blood, when a slight 
swelling was noticed upon the scrotum. The temperature, 
which had remained normal up to August 4th, rose suddenly 
to 39.4° C, and 40.2° C. On August 5th the suppuration had 
an odor of decomposition, and the coverings (?) had turned 



280 HERNIA. 

black ; the temperature remained the same. The sutures were 
all removed, the Lister dressings left off and replaced by- 
applications of lead-water; on account of a diarrhoea, which 
had set in, tincture of opium was given. The scrotum re- 
mained swollen. This condition remained unaltered until Au- 
gust 11th, the secretions still smelling badly, the only 
improvement being a slightly less swollen condition of the 
scrotum ; the temperature remained constantly above 38° C. 
On August 11th a gangrenous spot appeared on the tunica 
dartos, which gradually increased in size. On August 30th, a.m., 
paralysis of the right side was noticed by the point of the 
tongue, when extended, deviating to that side ; aphasia soon 
followed, and oh the following day the right facial nerve was 
also implicated. The bladder and bowels were evacuated into 
the bed, involuntarily. On the scrotum the gangrene had ex- 
tended, necessitating repeated incisions, each of which gave exit 
to foul-smelling pus. 

Symptoms of peritonitis did not appear, either now or after- 
ward. On August 17th clonic convulsions appeared in the left 
extremities ; the aphasia and paralysis continued unchanged ; 
the pupils, however, were, and remained equal, and the intellect 
was unaffected. The gangrene was circumscribed, and as the 
necrotic portions of tissue fell off successively, sound granu- 
lations appeared. On August 18th the patient asked for some 
wine ; he had become generally brighter, but complained of 
headache. His condition remained about the same for several 
days ; the wound and its surroundings improved slowly after 
the gangrenous portions had sloughed away and the swelling 
of the scrotum diminished. The paralysis continued the same. 
On August 27th acute vesicular breathing could be heard in 
both lungs ; crepitating rales and bronchial expiration could be 
heard behind the upper left lobe and the sense of suffocation 
increased gradually. The fever continued until September 2d, 
thirty-one days after the operation, when death occurred. 



OBSERVATIONS AND OPERATIONS. 281 

The autopsy, made on the following day, revealed endocarditis 
with verrucous excrescences upon the mitral valve, embolism of 
the arteria foss&3 Silvii sinistra (left middle cerebral) and em- 
bolic softenings in the left hemisphere, in the spleen, pleura, and 
right lung. There was pleuritis on both sides, and lympho- 
sarcoma of the retroperineal lymphatic glands. The inner wall 
of the peritoneum showed a protrusion at the site of the internal 
inguinal ring ; in the bottom of the funnel lay the silk ligature 
of the neck of the hernial sac surrounded by fresh cicatricial 
tissue, while further on were found two " heeled out " sutures at 
the entrance of the sac. No traces of peritonitis were seen. 
Death, in this case, was the consequence of the gangrene of 
the scrotum and the incidental suppuration which caused em- 
bolism in divers organs, though the lympho-sarcoma of the 
mesenteric glands pointed to a prolonged illness. 

Case VI. — V. Miiller, aged forty-one years, from Ilversheim, 
came to the Clinic on account of an incarcerated right inguinal 
hernia, which dated from two days before. The rupture had 
occurred suddenly, four or five years previously, while lifting a 
heavy load, but had always been easily reducible. On admission, 
the size of the hernia, which w r as expanded to its utmost, was 
42 ctm. from the external inguinal ring to the point of the scro- 
tum. The circumference of the scrotum at its base was 46 ctm., 
and in the middle 42 ctm. There had been no evacuation of 
the bowels for two days, and vomiting was almost constant. As 
baths, ice-bags, wrapping up the hernial protrusion in elastic 
dressings, and taxis while the patient was anaesthetized, were of 
no avail in reducing the rupture, I performed herniotomy, and 
in connection with it the radical operation. After the longi- 
tudinal incision over the greatest convexity of the tumor was 
made, a number of large veins had to be doubly ligated and ex- 
sected. In no place could the hernial sac be made out, but the 
muscular fibre of the prolapsed intestine could be recognized. 



282 HERNIA. 

A peritoneal protrusion was found in the upper part of the rup- 
ture, which, however, did not form a hernial sac, but was drawn 
down by the coecum and the end of the ileum ; then the pro- 
lapsed intestines could be recognized on drawing them forward 
after completely loosening them. 

The processus vermiformis, which was closely adherent to 
the testicle, without any peritoneal covering, had to be com- 
pletely loosened from its intergrowth with the cellular tissue, 
in order to make a reposition of the intestines practicable. The 
coecum and the ileum had to be similarly peeled out of the 
surrounding tissues ; more than thirty silk ligatures were neces- 
sary to stop the hemorrhage. After the intestines were com- 
pletely freed from their adhesions, and their contents emptied 
by rubbing down, their reposition could still not be accom- 
plished, and only after the orifice of the hernial sac had been 
somewhat dilated upward and outward, could they be pushed 
back into the abdominal cavity. The neck of the hernial sac 
was then so narrowed by five button-sutures that only the tip of 
the little finger could be introduced. The wound was then 
washed out with a five per cent carbol-solution, two drainage 
tubes were placed in position and the skin sewed together over 
them with button-sutures. At noon, after the operation, flatus 
escaped, and on the next day the first stool was passed. Vomit- 
ing occurred once, perhaps in consequence of the prolonged 
narcosis by chloroform. 

At the first change of dressings, on August 16th, a large 
quantity of bloody, serous liquid ran out ; the scrotum was not 
swollen, but there was a slight tumefaction immediately above 
the right ligamentum Poupartii ; there was also dulness, which 
remained unaltered for several days. The right lumbar region 
became somewhat sensitive to pressure on account of the drainage 
tubes — one of which extended far upward into the abdominal 
cavity — which were washed out at every change of the dressing ; 



OBSERVATIONS AND OPERATIONS. 283 

there was scarcely any suppuration. The subjective condition 
was good, notwithstanding the high temperature (39° C). On 
August 21st, considerable swelling of the scrotum was noticed, 
•which necessitated an incision. Later on, some gangrenous 
pieces of connective tissue appeared at the external wound and 
were removed. Stools occurred daily, until September 1st, when 
diarrhoea set in. On September 7th, a large quantity of pus 
was evacuated with the fasces, and smaller quantities often ap- 
peared up to September 20th. The rise of temperature had 
persisted until September 2d. The pulse, which never was 
above 92, went down to 88, then to 82. On September 18th 
the patient got up, wearing a truss, and was discharged on 
October 4th fully recovered. In coughing, no impulse could be 
felt at the seat of operation, but the beginning of an inguinal 
hernia appeared on the left side, which did not exist at the time 
the patient was admitted. 

Tins case is interesting in many respects. In the first place 
we had to deal with a coalescent non-reducible hernia which 
contained coecum, processus vermiformis, and the lower portion 
of the ileum, without a hernial sac. The smaller peritoneal pro- 
trusion, which was situated in the upper part of the rupture and 
toward the abdominal cavity, could not be termed a hernial sac ; 
at the utmost it could only have served for the admission of 
other portions of the intestines. 

There was here, probably, some congenital intergrowth of the 
processus vermiformis with the testicle ; if this is not admitted 
it is hard to understand how this intestinal appendix could have 
been completely drawn out of its peritoneal covering. Perhaps 
the coecum and the lower part of the ileum were drawn out of 
their peritoneal envelop by this same traction. Furthermore, in 
this case there was extensive suppuration, which led to intestinal 
perforation. It may be admitted that the chances for a radical 
cure were increased because union could be obtained between 



284 HERNIA. 

extensive wound-surfaces ; at any rate, Mtiller remained entirely 
cured for more than one year, as was shown by repeated exami- 
nations. 

On April 14th, 1879, a cicatrized cord, the thickness of a lead- 
pencil, could be felt along the right vas deferens. The operation- 
wound was flattened and movable. In coughing, increased 
impulse could be felt, but no intestine was forced out, and the 
inguinal ring admitted the finger. The left hernia had not 
increased in size. The patient had all this time worn a truss 
and was employed at hard labor. On September 14th, 1879, 
although the condition of the right side had remained perfectly 
satisfactory, an intestinal loop, the size of a small fist, appeared 
on the left side upon coughing. Thanks to a double truss, 
Muller could still work hard, and appeared fat and healthy. 
July 14th, 1880, the opening of the hernial sac on the right side 
allowed the passage of two fingers, and, on coughing, a hernia 
about the size of an apple pressed into the scrotum ; the left 
inguinal hernia had also increased in size, and, beside this, an 
umbilical hernia had made its appearance. 

Case VII. — K. Scharf, aged seventy-nine, was admitted 
August 30th, 1878, with a left strangulated inguinal hernia. 
According to the patient, the rupture had occurred three days 
before, during a violent fit of coughing. On August 28th, Dr. 
Feldbausch, who saw the patient at the poor-house of this town, 
ascertained the existence of a non-reducible hernia the size of a 
small apple. The patient had vomited twice ; after an enema, 
flatus and a small quantity of faeces passed off. On August 29th 
the tumor was said to be somewhat softer, but during the 
following night, vomiting of greenish — not fsecal — matter 
occurred three times. 

On August 30th, the broken-down old woman, who was failing 
rapidly, was brought to the surgical department in consequence 
of several enemata not having produced an evacuation. Upon 



OBSERVATIONS AND OPERATIONS. 285 

admission, I found that on the right side the inguinal canal was 
large enough to admit the tip of a finger, and on the left side, at 
the corresponding location, there was a hard lump the size of a 
walnut, exceedingly sensitive, which could not be reduced in 
size by any manipulation whatever. As the incarceration had 
already lasted two days, I abandoned the long-continued at- 
tempts at taxis and performed herniotomy. The incision w T as 
made under antiseptic precautions, and some bleeding vessels 
were taken up with fine silk. Proceeding further, we reached a 
thick layer of subperitoneal fat and afterwards the moderately 
thickened hernial sac, which contained a small quantity of 
liquid matter. The constriction was incised from within out- 
ward and a small, strangulated, dark-blue portion of the intes- 
tine, about the size of a hazelnut, was pushed back into the 
abdominal cavity, after some adhesions on its posterior surface 
had been loosened. The hernial sac, once freed, was cut off 
directly beneath the ligature, which I had made far up. The 
opening of the rupture was closed with a thick silk suture by 
perforating the columns of the inguinal ring, together with the 
peritoneum. When the drainage tubes were placed, the w T ound 
was closed and a Lister dressing applied. 

There is very little to relate of the history of the wound. 
There was very little suppuration ; the dressing was changed 
twice only — the first time to remove the drainage-tube and a 
few sutures, on the fourth day; and the second time, to' remove 
the last sutures on the sixth dav. The vomiting; had ceased 
immediately after the operation, but there w T as no stool until the 
sixth day, and they w r ere regular afterwards. September 13th, 
the patient got up for the first time, and was sent back to the 
poor-house on the 18th. She was obliged to take to her bed 
several times during the few following w T eeks, and died of pneu- 
monia about the middle of November. 

At the autopsy I ascertained that no trace of hernia was 



286 HERNIA. 

present. The peritoneum showed positively no depression at 
the internal inguinal opening, on which could be seen the encap- 
sulated ligature which had been used to close the ring ; towards 
this point radiated corrugations appeared, which had become 
adherent ; these, and also the silk thread, were covered with 
endothelium. 

Case VIII. — G. Wunsch, aged fifty-two, came to the surgical 
clinic on June 15th, 1878, on account of a fracture of the thigh. 
The broken bone united slowly, and only after the removal of 
several fragments of bone ; not until the end of September was 
recovery complete. In addition to the fracture, the patient had 
a left inguinal hernia reaching down to the knee, but which 
seemed to cause comparatively little trouble to the stupid 
patient. The size of the tumor could be diminished little by 
little, under pressure, but it was not entirely reducible. By the 
application of elastic bandages for several weeks, the recumbent 
posture, a fluid diet combined with massage of the scrotum and 
continued efforts at reduction, the hernia slowly decreased in 
size, and finally complete reposition could be effected. During 
this treatment at the hospital, a small rupture appeared on the 
right side. After the patient could get up and walk arouud, 
the application of a double truss would retain the right, but not 
the left inguinal hernia ; the truss and the suspensory bandage 
gave the patient so much pain that he could not endure them 
for any length of time. The orifice of the right hernial sac 
would easily admit two fingers, while that of the left would 
admit only one. The right hernia measured 27.8 ctm. from the 
outer inguinal ring to the lowest point of the scrotum, while the 
same measurement of the left gave 28.5 ctm. ; the circumference 
was 34 ctm. The impossibility of keeping the hernia reduced, 
and the inability of the patient to perform his customary labor, 
induced Prof. Czerny to perform the radical operation on Jan- 
uary 11th, 1879. 



OBSERVATIONS AND OPERATIONS. 287 

A tegumentary incision was made — about 10 ctm. in length 
— crossing the ligamentum Poupartii, and the hernial sac laid 
bare and opened ; it contained the sigmoid flexure and omentum. 
The hernia was reduced only by the simultaneous reduction of 
a portion of the sac. The orifice of the latter was then closed 
with the continued suture, and the whole replaced in the abdo- 
minal cavity. The inguinal canal was closed with five silk 
sutures. The non-reducible portion of the hernial sac (in which 
were found two localized indurations, one the size of the palm 
of the hand, the other about the size of a dollar) was exsected. 
The excised portion was cap-shaped, and had a diverticulum 3 ctm. 
long, 1.5 ctm. broad. The circumference was 33, and the depth 
8,10 ctm. The wound was irrigated with a five per cent, carbol- 
solution, drainage established, sutures applied, and the whole 
covered with a Lister dressing. It was necessary to change 
the dressings the next evening, as they had become displaced. 
On the fourteenth and sixteenth days some sutures were re- 
moved with each dressing. The scrotum became somewhat swol- 
len, and a moist carbolic-eczema appeared at several points. On 
account of the latter, Lister's dressing was discontinued, and 
fomentations of a two per cent solution of acetate of alum w 7 ere 
substituted. February 7th the eruption had disappeared, and 
the swelling of the scrotum had subsided ; on February 22d the 
patient got up for the first time, and on the 28th he was dis- 
missed with the following status : The scrotum measured from 
the external inguinal ring 18 ctm. in length, with a circumfer- 
ence at the root of the penis of 24 ctm. The left epididymis was 
somewhat thickened, and in the left scrotal sac a firm fibrous 
mass was discovered. On standing, a protrusion the size of a 
pigeon's egg appeared at the left inguinal ring, and could be 
enlarged to double this size by coughing ; the inguinal ring was 
passable for the tip of the finger. The right hernia was about 
the size of an apple. A double truss now retained both hernia? 
without causing any pain. 



288 HERNIA. 

: Wunsch did not return again to the surgical clinic, but. on 
account of his continued inability to work he was admitted on 
May 18th, 1879, to the asylum of Sinsheim. 

According to a note which I have received from the medical 
director of that asylum, Dr. Langsdorf, there is now a reducible 
hernia of the right side about the size of an apple, the opening 
of the sac measuring 3 ctm. in diameter; on the left side, an 
irreducible hernia the size of the two fists has protruded through 
an opening measuring 2 ctm. The length of the hernia from 
the external inguinal ring is on the right side 15, on the left 25 
ctm. ; the circumference of the scrotum at its base is 37 ctm. 

Case IX. — W. Hollweck, ten months of age, was admitted 
January 9th, 1879, on account of a very large, double, reducible 
inguinal hernia. The ruptures were noticed soon after the birth 
of the child, but nothing had been done to secure relief. They 
had increased in volume so that they measured from the hernial 
opening 10 ctm. on the left side, and on the right 9 ctm. ; the 
circumference was 25 ctm. One more attempt was made to 
keep the hernia in place by a well-fitting double truss, but while 
it was difficult to reduce the hernial in this constantly crying 
child, it was altogether impossible to retain them after reduction; 
they protruded immediately after each reposition, and all at- 
tempts at cure by this means were abandoned. The radical 
operation was performed on both sides at one sitting, January 
24th, 1879, by Prof. Czerny. 

Under antiseptic precautions an incision, 4-5 ctm. in length, 
was made over the left hernial tumor, and after exposure of the 
sac — which was very thin — the hernia was reduced. 

The hernial opening was closed by means of two catgut su- 
tures, the sac was ligated and then divided, whereupon it was 
discovered that the ligation had not been complete, and that 
through its posterior portion an entrance could be effected into 
the abdominal cavity. Two drainage tubes were inserted, and 



OBSERVATIONS AND OPERATIONS. 289 

the wound was closed with five silk sutures. The same method 
was adopted on the right side, except that the hernial open- 
ing was closed with two silk sutures ; the now opened hernial 
sac was pushed aside, a drainage-tube was inserted, and the 
wound was united by silk sutures. 

On account of the tenderness of the skin, a dressing of thymol 
gauze and salicyl-wadding was used. Temperature at night was 
37.9° C. (100° R). 

For a short while the dressings had to be changed at least 
once daily — often several times a day — on account of their 
being soiled by the faeces and urine. Slight swelling appeared 
in the left inguinal region, but not in the right. On January 
28th, as the wound of the right side had ceased suppurating, the 
drainage-tube was removed from this side ; the tube on the left 
side was allowed to remain, as there was still some secretion. 
The course of recovery was entirely aseptic until February 2d, 
when the coverings were found to be discolored, without, how- 
ever, any rise of temperature being observed. The swelling 
upon the left side subsided gradually, and on February 13th 
there was only a slight, superficial wound upon this side, while 
the right side had been firmly healed for several days. A push- 
ing down of the viscera could be felt on both sides when the 
child cried, but no protrusion appeared through either inguinal 
canal. The patient was dismissed on February 19th, wearing a 
double truss. 

At a later examination, on September 19th, 1879, it appeared 
that the cure upon the right side had been permanent, but upon 
the left side there was a hernia the size of a small apple. The 
mother, who had taken off the truss soon after the operation, 
was advised to reapply it, and to keep it on night and day. For 
three weeks this advice was carried out, and when the child 
was examined again, July 15, 1880, both hernias were com- 
pletely cured; no protrusion of the viscera appeared in the 



290 HERNIA. 

inguinal canal of either side, and only a very slight impulse was 
felt. 

Case X. — G. B., aged forty-one, was admitted, May 16, 1879, 
with a rupture of the linea alba. He had been under the care 
of a physician since January of the same year, on account of a 
feeling of pressure and a steadily increasing pain in the region 
of the stomach. The tumor appeared directly in the median 
line, about 2 ctm. above the navel, was white, elastic, sensitive 
upon pressure, and could be partially reduced, allowing the tip 
of the little finger to be introduced through the opening in the 
abdominal wall. 

On May 17th, after a thorough evacuation of the bowels, the 
operation was performed by Prof. Czerny. A transverse incision, 
about 2 ctm. in length, laid bare the tumor, which was as large 
as a hazelnut. After dividing the skin and subcutaneous cellu- 
lar tissue, a dense mass of fat, enclosed in a thick membrane of 
connective tissue, was exposed, and could be traced by a pedicle 
through the opening in the linea alba. This small subserous 
lipoma was drawn out, its pedicle ligated at the lowest possible 
point with thick catgut, and cut off directly beneath the liga- 
ture; it happened that a small portion of the peritoneum was 
also ligated, but no intestine was included. The stump of the 
pedicle was loosened from its adhesions to the hernia, and was 
returned to the abdominal cavity. The hernia itself was re- 
tained by the introduction of two catgut sutures, from above 
downward ; these were then cut short, and the wound was closed 
by silk sutures, — a small drainage-tube having been placed in 
the middle of the wound. In the evening the patient com- 
plained of pain in the region of the stomach, which, however, 
was relieved by morphia (0.015) and the application of an ice- 
bladder. The wound healed without suppuration, and on the 
sixth day the dressings were removed entirely. The pain in 
the region of the stomach reappeared once — on the day after 



OBSERVATIONS AND OPERATIONS. 291 

the operation, — and then disappeared altogether. The patient 
was dismissed June 1st, wearing an elastic bandage with a pad. 
The patient, after dismissal, wrote several times, and also came 
once himself; he reported no return of the pain in the gastric 
region. 

Case XL — K. Kirchner, aged thirty-five, came to the sur- 
gical ward on August 18th, 1880. For several days small evac- 
uations, consisting of very hard fasces, had been secured only by 
means of enemata, and, according to the report of his attending 
physicians, there had been complete constipation since August 
10th. Injections of large quantities of warm water, three doses 
of calomel, each consisting of 0.5, with 1.0 of jalap, ol. ricini 
with ol. tiglii, and finally mercurius vivus (August 16th), did 
not afford any relief to the patient ; tinct. opii simpl, which was 
given on account of the severe colic, was no more successful. 
On admission, the patient's appearance showed a depressed gen- 
eral condition, the tongue was dry, the pulse small and accele- 
rated, temperature 37.8° C, the abdomen very large and so 
tender to the touch, especially above the umbilicus, that an 
exact examination was impossible. After the administration of 
tinct. opii, and repeated enemata of large quantities of liquids 
(which, however, were dejected free from faecal matter), the patient 
felt better. The abdominal pain again returned with violence, 
and the meteorism persisted, even after several evacuations had 
occurred, on August 19th. On August 20th, a swelling the size 
of a hazelnut, extremely painful on pressure, which had been 
noticed upon the previous day, and had been taken for a hernia 
epigastrica, could be plainly distinguished. 

At noon of the same day, his condition remaining the same, 
I performed herniotomy under antisepsis. Division of the in- 
tegument exposed to view a small adipose tumor, which could 
be plainly distinguished from its surroundings, and appeared 
inflamed. After it had been completely separated from con- 



292 HERNIA. 

nections with other tissues and drawn out from the margins of the 
hernial opening, — the latter being situated in the linea alba — 
it was ligated as low down as possible and excised. The pedicle 
was returned to the abdominal cavity, the opening in the 
aponeurosis of the abdominal muscles closed by means of a catgut 
suture, and the wound united by four silk sutures. After the 
operation the patient felt greatly relieved, and the tenderness 
above the umbilicus had to a great extent disappeared ; the 
abdomen was soft, had become smaller, and was not sensitive to 
pressure. On the next day there were several evacuations. On 
August 22d, the sutures were removed from the wound, which 
had apparently healed by first intention ; diarrhoea occurred 
repeatedly upon the 22d, and on the 24th hard scybalse were 
passed, to which adhered small black granules of quicksilver. 
After this, all the intestinal discharges were washed and care- 
fully examined for quicksilver, and on the 25th, 90 grin., partly 
oxidized, were found, and again on the 26th, 80 grm. At this 
time, too, a small quantity of pus was discharged from the upper 
part of the wound, which until now had remained closed ; on the 
28th, several furuncles appeared in this neighborhood, which, 
after the separation of a few gangrenous sloughs, healed, to- 
gether with the operation wound. 

Until August 29th, all the faeces discharged contained small 
granules of quicksilver, and the entire amount collected was 
180 grm. No salivation occurred on account of the presence 
in the body of this large quantity of metallic mercury; on 
the contrary, as is stated above, the tongue was entirely dry 
in the beginning, and only gradually became somewhat moist. 
The thermometer showed a morning temperature of 37.6° C. 
to 38° C. from the 18th to the 22d ; after this date the temper- 
ature was normal. On September 10th, the patient, who now 
had one daily evacuation of the bowels, left the bed, and on 
September 19th was discharged. About the middle of December, 



OBSERVATIONS AND OPERATIONS. 293 

1880, K. was known to be perfectly well ; the cicatrix was not 
tender, and no colic or derangements of digestion had occurred 
in the mean time. 

• The last two cases show how small hernias of the linea alba, 
even if they do not contain segments of the stomach or intestine, 
may give rise to serious disturbances. In the first case, the 
hernia adiposa, as large as a hazelnut, had drawn out through 
the hernial opening in the abdominal wall a small peritoneal diver- 
ticulum, while in the other patient nothing of this kind could be 
observed. In the second case, we might be doubtful as to the 
condition present, if there had not been symptoms of peritonitis 
in connection with the hernia epigastrica ; but the extreme ten- 
derness of the hernia, its appearance at the operation, the sub- 
jective relief after herniotomy and the sudden disappearance of 
the meteorism and abdominal tenderness made it most probable 
that the peritonitis was directly dependent upon the hernia. 

The occurrence of these small hernias in the linea alba or in 
its vicinity, between the umbilicus and the xyphoid process, is 
certainly not a rare one. Sometimes, however, these hernias 
adiposas are not looked upon as the cause of the patient's suffer- 
ings ; sometimes, even, they are overlooked, if a careful examina- 
tion of this special region is not made ; I have seen three other 
cases in our surgical clinic, who complained of pain in the gas- 
tric region, and on whom these small, somewhat tender hernias 
could be demonstrated. It is certainly advisable in all cases 
where grave symptoms are caused by these ruptures to excise 
them, and close the hernial opening, after having loosened and 
returned the pedicle ; even if a small portion of the peritoneum 
should also be excised, the operation, performed under antiseptic 
precautions, will nevertheless be practically without danger, and 
rapid union of the wound may be secured. 

In order to facilitate a review of all the material from which 
this report is made up for the final conclusions, I shall now add 



294 • HERNIA. 

the principle features of the five cases operated on by Prof. 
Czerny,* and taken from the complete reports of these cases 
previously published : — 

Case XII. (loc. cit, p. 15). — J. Ehret, one and a half years of 
age, was operated on, July 26th, 1877, on account of a very 
large double inguinal hernia, which could not be retained by 
trusses. On the right side the hernial opening was closed by 
four button-sutures of carbolized silk, the sac was partially 
ligated, the wound washed out with a five per cent, carbol- 
solution, and drainage established. The left hernial opening- 
was also closed with three silk sutures, the neck of the sac 
ligated and drained. A subcutaneous phlegmon developed on 
the right side, and was incised ; from the opening thus made 
the sutures and the ligature employed in the operation pro- 
truded. Union by primary intention took place on the left 
side. On August 25th, the boy, apparently cured, was dismissed 
without the application of a truss. 

In the early part of September a small abscess appeared on 
the left cicatrix, and was opened ; the hernial opening on this 
side was very small, impulse could be plainly felt, but no pro- 
trusion could be discovered. On the right side a knuckle of 
intestine protruded when the child cried, but returned sponta- 
neously during rest. September 25th, the right hernia was still 
enlarged, and after each reposition of the intestine the sac was 
found to be occupied by a cord, — supposed to be the vermiform 
appendix, — which had been seen in the hernia at the time of 
the operation. Since this last examination the patient has worn 
a truss constantly. At a late examination, on September 21st, 
1879, the hernial opening of the left side could scarcely be 
found, while that of the right side was large enough to admit 
the tip of the little finger. When the child cried or screamed, 
the inguinal regions of both sides swelled out somewhat, but no 
* Czerny, V., Beitrage zur operativen Chirurgie. Stuttgart, 1878. 



OBSERVATIONS AND OPERATIONS. 295 

intestine entered the inguinal canals. The father's statement 
that at times there was a protrusion from the right canal could 
not be verified at the examination, though the little one cried 
constantly, — possibly the father had noticed the testicle, which 
was strongly retracted, and mistook it for a hernia. On Sep- 
tember 1st, 1880, the left inguinal canal was too small to admit 
the tip of the little finger ; and although an impulse could be 
felt when the patient coughed, there was no intestinal protrusion. 
The right canal admitted the little finger, and coughing caused 
the protrusion of a hernia as large as a pigeon's egg, which, how- 
ever, was easily reducible, and could be retained by a truss. 
This rupture had enlarged gradually for the past six weeks, 
during which time the patient had been suffering from the 
whooping-cough. After reposition of the intestinal loop, the 
cord — above mentioned as probably being the vermiform appen- 
dix — was felt lying along the inguinal canal. Since spring he 
had worn a single (for the right side) instead of a double truss ; 
the latter was again recommended on account of the severe 
couching:. 

Case XIII. (loc. cit., pp. 19 and 38). — Fr. Eachel, aged 
seventy years, was operated on, August 2d, 1877, for a very 
large right inguinal hernia (there was also a hernia of the left 
side as large as an apple). The hernial opening was closed with 
silk button-sutures, the sac was ligated high up with silk thread, 
washed out with a five per cent, carbol-solution, and drained. 
Complete union by first intention occurred, and on September 
12th the patient was discharged, wearing a double truss. In 
November, the impulse on the right side was stronger than 
normal, and a hernia incipiens appeared to be forming. Eachel 
did not present himself again, but his son said that the hernia 
had not enlarged, nor had it caused any trouble to the patient 
up to the time of his death, which occurred in January, 1879. 

Case XIV. (loc. cit., pp. 22 and 38). — Martin Wallbauer, aged 



296 HERNIA. 

sixty-three years, was operated on, August 8th, 1877, on account 
of an incarcerated right inguinal hernia. The hernial opening- 
was closed with three strong silk button sutures, the hernial sac 
was ligated with a strong silk thread, its cavity washed out with 
sponges which had been immersed in a five per cent, carbol- 
solution, and drainage established. The wound healed in six 
days without suppuration, the patient left his bed on the 24th, 
and was dismissed on the 28th ; standing or straining caused no 
protrusion. In November, 1877, the patient's condition was the 
same as at the time of his discharge. On September 13th, 1879, 
the patient presented himself again for examination, at which it 
was discovered that there was a hernial opening on the right 
side, admitting the finger, and from it protruded a tumor the 
size of a pigeon's egg\ He had worn his truss irregularly, but 
according to his statement, the recovery had been complete for a 
year. On July 15th, 1880, a hernia interstitialis was found on 
the right side ; the hernial opening appeared tense, but the 
hernia itself had not increased in size. During this time an- 
other hernial opening had formed, into which a finger could 
enter. 

Case XY. (loc. cit., pp. 22 and 38). — George Kinzinger, aged 
forty-eight, was operated on, June 14th, 1877, for a faecal fistula 
in the hernial sac. After direct union of the intestinal wound 
with three catgut sutures, — above which were applied a second 
row of five button-sutures, — and after returning the loop to the 
abdominal cavity, the hernial opening was closed with a corset- 
suture of thick catgut, crossed fourfold, the hernial sac was 
ligated, also with catgut, its cavity washed out with five per 
cent, carbol water, and drainage established. On the sixteenth 
day after the operation the wound had completely healed, the 
patient left his bed on June 9th, and about the middle of July 
was dismissed. During August and September his condition 
remained the same as at the time of his discharge. During 1878 



OBSERVATIONS AND OPERATIONS. 297 

a small hernia again appeared, about the size of a goose era. 
On July loth, 1880, it had not increased in size, the hernial 
opening admitted the finger, and felt very tense. The patient 
appeared healthy, notwithstanding very hard labor at his trade, 
— that of carpenter, — all kinds of food agreeing with him, and 
he never suffered from constipation or intestinal pains. 

Case XVI. (loc. cit, pp. 32 and 38). — The radical operation 
was performed on Conrad Kraus, aged forty, on July 2d, 1877; 
also for a faecal fistula in the hernial sac. In this case, also, the 
intestinal wound was closed by seven catgut button-sutures, 
over which was applied a second row consisting of seven sutures; 
the hernial opening was then united by means of the catgut 
corset-suture, and the hernial sac was partly ligated at its neck, 
as the incision into the sac reached too high up to be accessible 
for ligation. On August 7th the patient was dismissed, cured. 

In November, 1877, the impulse of the intestine in the in- 
guinal region was found to be somewhat greater than normal, 
but there was no protrusion. During the year 1878 a hernia 
again appeared, and on September 14th, 1879, it was as large as 
a goose egg, and remained of this size until July 18th, 1880, when 
the viscera protruded, together with the external portion of the 
inguinal canal, but did not descend into the scrotum, and was 
reducible. The truss has been worn ever since, the patient looks 
well, can take any kind of food without difficulty, and has regu- 
lar evacuations of the bowels. 

Summary. — In summing up the main features of the above 
enumerated cases, we find the nineteen radical operations were 
performed on sixteen patients, ten times for single, three times 
for double inguinal hernia, and two times for hernia of an adi- 
pose tumor in the linea alba. The indications for the radical 
operation were incarceration of the hernia in five cases (I., II., 
III., VI., VII., XIV.), the inability to retain the hernia by means 
of trusses in five cases (IV., V., IX., XII., XIII.), irreducible 



298 HERNIA. 

hernia on account of adhesions, in two cases (VIII. , XII.), and 
faecal fistula? in the hernial sac in two cases (XV, XVI.). 

Concerning the methods of operating, we may divide the cases 
(with the exception of the two ending fatally), one as a result of 
pyaemia (V), the other from contusions independent of the 
operation (II.), as follows : — 

Complete ligation of the neck of the sac, together with suture 
of the hernial opening, was made in nine cases of inguinal her- 
nia— (IV., V. (double), VII. (left), XIV, XV, XVI), and in 
the two cases of hernia of adipose lipomata in the linea alba 
(XL). The hernial sac in these cases was washed out with a 
five per cent, carbol-solution and drained ; it was extirpated only 
once, and then because it was small and had been loosened from 
all its connections during the operation. 

Healing of the wound occurred six times without suppuration, 
within six to ten days (IV (left), VII, X, XIV, XII. (left), 
XIIL), four times after suppuration for fourteen, sixteen, thirty- 
six, and thirty-nine days (XI, XV, IV (right), once death en- 
sued V.). All patients were dismissed wearing a truss. 

In six adults with inguinal hernia, local recidives occurred 
several months after, and at the point of operation (IV. (double), 
XIIL, XV, XVI.) ; in one case only was the recidive found after 
the lapse of a year, but it was small and could be easily retained 
by a truss. The patients with hernia of lipomata in the linea 
alba (X, XL) were completely cured. 

In the adult female (VII.) who died about six weeks after the 
operation, of pneumonia, no trace of a hernial opening and no 
e version of the peritoneum could be discovered at the autopsy. 
In the case of the child (XIIL left), the cure remained perma- 
nent, as shown by a recent examination three years after the 
operation. 

Partial ligation of the sac, in addition to suture of the hernial 
opening, was practised on two children (IX. left, XII. right), on 



OBSERVATIONS AXD OPERATIONS. 299 

account of its extreme thinness ; recovery was complete in 
twenty-four and thirty days. In one child (IX.) a local re- 
cidive, developed several months after the operation, was cured 
by wearing a truss and remained so (as was demonstrated re- 
cently) ten months after its application. In another child 
(XII.) a recidive also occurred, and was retained by a truss for 
a whole year, but recently reappeared again in consequence of 
whooping-cough. 

The hernial opening alone was closed in four cases ; in one 
adult (VI.), because there was no hernial sac, in another (VIII.), 
because the sac had to be partly pushed back into the abdominal 
cavity to enable the reduction of the hernia ; then, in two chil- 
dren (I., IX. right), on account of its thin, friable condition. 
Healing was complete in fourteen, eighteen, twenty-seven, and 
fifty-one days (I., IX., VIII., VI.). 

In one adult who had an exceedingly large hernia (VIII.), a 
recidive occurred several weeks after the operation, while in the 
other (VI.) the cure remained for one year, after which time a 
partial recidive appeared. Besides, in both of these patients the 
hernia developed on the side which had not been operated on — 
in one an umbilical hernia, also. Both children were perma- 
nently cured after recovery from the operation, as was demon- 
strated in the one (I.) after thirty-four months, and in the other 
after nineteen months. The neck of the hernial sac alone was 
ligated in one adult (III.), the wound healing in twenty-one clays 
with little ulceration ; but here, also, a recidive occurred, which 
remained slight for seven months. 

As to the ages of the patients operated on, the following re- 
sults — independent of the method of operating adopted in each 
individual case — may be given from the foregoing statements : 
One death occurred in thirteen radical operations upon twelve 
adult patients; in the two cases of hernia adiposa linise alba?, 
the cure was permanent, and in the others it lasted from several 



300 HERNIA. 

months to two years, after which time recidives appeared either 
locally or directly above the site of operation ; twice a hernia of 
the other side, and in one case an umbilical hernia in addition. 
In all these cases, however, the local recidives remained small 
and could easily be retained by a truss, even in those cases 
where the operation had been performed for the relief of very 
large herniae. 

Out of six radical operations in four children, death occurred 
in one case independent of the operation. In three cases, which, 
on account of the size of the hernia, would not have recovered 
spontaneously, with one exception the cure remained permanent 
from the moment of the operation, and was demonstrated after 
nineteen, thirty-four, and thirty-seven months (IX. right; I., 
XII. left) ; in two, local recidives developed, one of which, how- 
ever (IX. left), could be retained by means of a truss, and had 
remained cured when it was last examined, ten months later. 

Conclusions. — We may be encouraged by these statistics to 
perform the operation for the radical cure of hernia, in adults, un- 
der the following circumstances : Where the hernia is strangulated ; 
— as, by the radical operation, danger to life is not increased ; for 
very large non-reducible herniae which render the patient unfit for 
work, or which, on account of their size, cause intolerable diffi- 
culties ; and finally, for faecal fistulas in the hernial sac. These 
latter various conditions — the relief of which was formerly only 
very exceptionally attempted — are included in the list of opera- 
tions, on account of the confidence in the harmlessness of such 
interference under antiseptic precautions. Even if, in such 
cases, no radical cure be obtained, these herniae or their recidives 
may be retained by a truss. In cases of small uncomplicated 
herniae, the operation is to be rejected, as a permanent cure can- 
not be promised with certainty, and the patient would not be 
able to dispense with the truss. Without restriction, the radical 
operation is to be recommended in small children, for strangu- 



OBSERVATIONS AND OPERATIONS. M 

latecl and very large hernias which are difficult of reduction, or 
which cannot be cured by wearing a truss, as, according to our 
observations, the final result would be even more favorable than 
in adults, if the antiseptic dressings could be applied with the 
same exactness as in the latter. The dangers of the operation 
will be much diminished by frequent change of the dressings — 
although this makes the after-treatment extremely troublesome 
and requires much time — and by the ligation of the closed her- 
nial sac. In older children, antisepsis may be carried out with 
tolerable certainty, and favorable results will be obtained by the 
radical operation in these cases. 

Which method of operation is to be preferred, will, naturally 
enough, not be decided by the results obtained in these few cases. 
As long as it remains doubtful whether the constriction of the 
hernial opening or the ligation of the neck of the sac is the most 
essential to a cure, it will be the more rational to combine both 
procedures where it can be done. There will be plenty of cases 
in which, necessarily, only the one or the other method can be 
selected, and these will help to solve the question, which 
method is to be considered the more important. After the ap- 
plication of the suture, the constriction of the hernial opening 
could be demonstrated for weeks ; it could also be shown that 
the contraction continued and the columns became generally 
more tense. Even if in some patients an enlargement of the 
opening occurs, it has never attained, in our cases, the size that 
it had before the operation. If, in addition, the hernial sac is 
ligated and obliterated on a level with the internal hernial 
opening, the peritoneum will certainly be less easily everted 
through such a narrow opening, than if it is drawn over a wide 
hernial opening. It is, however, a doubtful question to me, 
whether according to our experience, the success of the opera- 
tion may be promoted by producing an ulceration in the hernial 
sac, as has been asserted by other operators. According to the 



302 HERNIA. 

above record, it is desirable to secure union as early as possible ; 
for the cure remained permanent in several instances, or at least 
recidives did not occur so soon, in those cases where the wound 
healed by first intention. This was especially remarkable in 
the case of two children (IX., XII.), in one of which the wound 
suppurated for a long time on the one side, while on the other it 
had healed prima intentione. 

For comparison with other methods of operation, the author 
would bes? leave to make the following conclusions of his own. 
It is true the most of the cases here detailed were serious ones, 
but still the total number of real, permanent successes is only 
three out of the nineteen operations. The total number of deaths 
was three ; of partial cures, three; of cures for one year, four ; 
and of failures, six. In nearly all the cases, active suppuration 
was a consequence of the operation, and the average length of 
treatment was thirty-three days ; so that it does not seem that 
the Antiseptic Method of Ligation is, after all, so simple and 
successful as some have claimed it to be. 



CHAPTER XL 

Artificial Anus and Wounds of the Intestines. 

artificial anus. 

Artificial anus is applied either to the opening made in the 
skin by nature, in consequence of the mortification of a strangu- 
lated intestine, or to the opening made artificially by the surgeon, 
when the bowel has become strangulated and gangrenous. 

There is also an artificial anus made by the surgeon's knife in 
the infant, when it has had the misfortune to be born into this 
world with imperforate rectum, or' in the adult for cancerous or 
other permanent obstructions of the rectum. This is so far foreign 
to our present study, however, that, although highly interesting, 
it will demand only the briefest mention. 

The place chosen for the incision varies. Littre, in 1720, 
chose the left iliac region, opening the sigmoid flexure through 
tthe peritoneum, but the operation was not performed until 1776. 
Callisen, on the other hand, chose the left lumbar region, at- 
tempting to open the descending colon without injuring the 
peritoneum. 

Littre made an incision about two to three inches in length, 
from the level of the anterior superior iliac spine and parallel 
to Poupart's ligament. The peritoneum was divided, and search 
made in the left iliac fossa for the sigmoid flexure. It often 
happens that in the infant this flexure is in the right fossa in- 
stead of in the left, as normally. When found, it is to be 
stitched to the external incision that was made. 



304 HERNIA. 

The superiority that is claimed for Callisen's method depends 
upon the fact that the left colon is devoid of peritoneum in the 
posterior third of its circumference, especially when distended. 
Another advantage is that the anus is made in the posterior, in- 
stead of in the anterior, aspect of the abdomen. There is, how- 
ever, no certain indication of the limits of the extent of the 
peritoneum upon the colon, and it has been found by statistics 
that the operation does not possess its much-vaunted superiority 
of not injuring the peritoneum. 

Amussat proposed a valuable modification of Callisen's method. 
In 1839 he operated on a case by making an incision, about two 
fingers' breadth above the crest of the ilium, beginning at the 
external border of the sacro-lumbalis and lonoissimus dorsi, and 
extending outward about five fingers' breadth. The muscular 
layers are divided first transversely and then vertically in order 
to make a crucial incision, and thus better expose the intestines. 
A crucial incision is also made in the colon. After the intestine 
has been evacuated, and, if necessary, washed with injections of 
warm water, it is drawn forward, and fastened to the skin by 
four interrupted sutures. 

In newly-born children the presence of the kidney singularly 
inconveniences the surgeon, especially if it be at all abnormal in 
its position. It must be borne in mind that the colon is on the 
external side of the kidney, so that, in order to find the former, 
the kidney must be pushed to the inner side and to the rear. 

As to the practical results of the formation of an artificial 
anus, whether in the infant or in the adult, it must be confessed 
that the operation is a very dangerous one, and, at the very best, 
can secure to the patient only a miserable and loathsome exist- 
ence. It is a very doubtful question whether to submit an 
adult to such an operation, or w T hether to leave nature to form 
an artificial opening by a slough, and then take the chances of 
recovery ; but in the case of an infant, probably the best course 



AETIFICIAL ANUS. 305 

is to leave nature to herself, and let her have her way without 
operative interference. 

After this brief diversion, we will return to the division of 
the subject that more especially interests us at the present 
moment, viz., the artificial anus which is the result of an intes- 
tinal strangulation. This variety occurs most frequently in the 
inguinal, scrotal, and femoral regions, and, as a rule, involves 
only the small intestine. Whatever fsecal discharge takes place 
is involuntary and continuous, owing to the entire absence of a 
sphincter. 

Artificial anus differs according to the extent of the opening 
that is formed in. the intestine. When only a small ulcerated 
opening exists, which does not however interfere with the con- 
tinuity of the intestine, but which still allows some of its 
contents to escape, we speak of it as a faecal fistula. The per- 
foration is usually at the fundus of the strangulated knuckle of 
intestine, that is, at the point most distant from the mouth of 
the sac ; it often heals spontaneously. There may be a single 
fistulous orifice or there may be several openings. When, how- 
ever, as is usually the case, there is only a partial sloughing of 
the intestines, we find, on account of the different powers of re- 
sistance which the coats of the bowel possess, that a groove is 
formed on the serous, but an ulceration on the mucous surface ; a 
re-entrant fold is thus made which obstructs the passage of 
fiecal matter from the upper to the lower part of the intestine. 
Very rarely, the adjacent serous walls become adherent from 
long-continued pressure, ulceration eats through them, and the 
continuity of the canal is restored. 

On the other hand, slou^hin^ of the entire bowel takes place 
at the mouth of the sac, continuity is destroyed, and faeculent 
matter escapes from the opening. The two ends of the intestine 
lie parallel for a greater or less extent, and the partition wall or 
spur-like portion of the two adjacent walls of intestine, called 



306 HERNIA. 

the " Eperon " (the full importance of which was first pointed 
out by Dupuytren), may act as a valve and hinder the passage of 
faeces. Hence the proximal orifice of the intestine becomes 
dilated, while the distal portion of the bowel, having ceased to 
transmit faeces, becomes smaller. This is an almost constant 
feature of " anus contre nature." When the external opening is 
large, there is also a tendency for the mucous lining to become 
everted and form a prolapsing tumor. If the slough has been 
in a knuckle of intestine, the external opening will present an 
appearance not unlike a double-barrelled gun, the dividing sep- 
tum being the "eperon" just mentioned. A more rare form, 
mentioned by Malgaigne, is where there are two points of divi- 
sion, the anus opening by two orifices near each other, but sepa- 
rated by a bridge of skin. If, however, the slough has been in 
the parietes of a straight portion of intestine, the external orifice 
will be single and of much simpler treatment. 

It is important to notice that, although the bowel gives way 
within the peritoneal cavity, the faeces do not become extra- 
vasated into this, but escape externally. This is because the 
bowel at this point loses its peristaltic action, and the neighbor- 
ing parts become inflamed. The lymph which is thrown out 
consolidates these parts both to one another, and to the parietal 
peritoneum, so as to inclose completely the gangrenous portion 
of the intestine. It is therefore worthy of the surgeon's atten- 
tion not to disturb the adhesions which may have formed be- 
tween the sides of the opening and the neck of the sac. 

The treatment of artificial anus that has thus formed is two- 
fold, — to destroy the " eperon," and then to close the external 
opening. A permanent opening, however, often remains in spite 
of all remedial efforts. The margins of the opening may then 
be sustained by a circlet of ivory or steel, padded around its cir- 
cumference with horse-hair and covered with oiled silk, or else 
a receptacle may be worn and kept in place by an elastic band 



AKTIFICIAL ANUS. 



307 



or truss, until inconvenience warns the patient of the pressing 
need to empty it. 

Schmalkalderi s Operation. — Schmalkalden, in 1798, was the 
first who thought of destroying the "eperon." He passed a 
stylet, protected on the point with wax, into the inferior end. 
After piercing the "eperon" in this way, he divided it with a 
prohe-pointed bistoury. To enlarge the opening, he divided it 
still further with scissors, but a complete cure did not result 
for twelve years. Physick, of Philadelphia, in 1809, passed a 
thread through the base of the " eperon," and formed a ligature 
which he allowed to remain in situ for a week. But these opera- 
tions are dangerous, since the limits of adherence may be passed, 
and an opening made into the peritoneum. 

Dupuytrens Operation. — In 1813, Dupuytren attempted 
Schmalkalden's operation, but, perceiving its dangers, he in- 
vented an enterotome, like a pair of forceps, with separable 




Fig. 63. — Dupuytren's Method and Enterotome. 



blades ; the female blade has upon one of its sides an undulating 
groove admitting the sharp edge of the male blade. The blades 
are approximated by a thumb-screw. The patient being placed 
in the position for the operation for strangulated hernia, the 



308 HEKNIA. 

septum is found compressed between the blades of the instru- 
ment. The two ends of the intestine are thus made parallel for 
a great extent, and are made to adhere by the compression. 
Usually the instrument becomes loose by the eighth day, leaving 
a dry eschar in place of the " eperon." When this has fallen off, 
there is left only a hard ridge at both sides of the opening. 

Dupuytren's method has been modified by Iiotard, Blandin, 
and Gross, to obtain an increased loss of substance ; by Nelaton, 
Eichet, Panas, and J. Mason Warren, to secure an easier appli- 
cation; while Langier lined the jaws with caustic to hasten 
their action. The instrument sometimes causes severe pain, and 
Jobert cites a case where all the symptoms of strangulation were 
produced by too tight compression. The method is not in all 
cases trustworthy, and may be extremely dangerous to life. 

The fistula, or external opening in the integument, was formerly 
treated by cauterization with sulphate of copper or nitrate of 
silver, by compression, or by the quill suture. The mucous 
membrane which has become adherent to the skin, so long as it 
is present, offers an insurmountable obstacle to the coaptation of 
the walls. Its removal, as I have just said, was formerly at- 
tempted upon general .principles. Yelpeau freshened the parts 
adjacent to the intestine, and fastened them together by a suture 
not touching the intestine. By this method a conical cavity 
was formed, with the apex pointing towards the intestine. 
Malgaigne separates the intestine from its external adherences, 
taking care not to injure the peritoneum. The two lips of the 
intestine are then united by a ligature, so as to bring their ex- 
ternal surfaces back to back ; the freshened integument is united 
by a twisted suture. The essential feature in the operation is 
to separate the intestines from their attachments and to fold 
the two lips inward. 

Enterotomy. — When the surgeon is convinced that the bowel 
has become gangrenous from strangulation, or will speedily be- 



AKTIFICIAL ANUS. 



309 



come gangrenous if the inflammatory processes are not checked, 
he should seriously consider the operation of enterotomy. This 
operation was first performed by Nekton upon a patient of 
Trousseau's for intestinal obstruction. The parietes over the 
hernial protrusion where the gangrene is suspected are carefully 
divided, layer by layer, until we come to the most deeply-seated 
aponeurosis. Proceeding slowly, tying all vessels that may be 
severed, and sponging carefully, the surgeon cuts down to the 
peritoneum. This is raised by the small forceps and divided. 
Then, with the greatest precautions, a silver thread is carried by 
a curved hollow needle through the intestine and abdominal 
walls, until enough sutures are in to fix everywhere the gan- 
grenous patch of intestine to the opening that has been made. 







Fig. 64. — Artificial Anus. 

The gangrenous patch is then excised, and the patient given 
all possible chances for recovery. The inconveniences which 
the patient suffers from the constant flow of faecal matter from 
the permanent artificial anus thus formed have already been 
spoken of. 



310 



HERNIA. 



WOUNDS OF THE INTESTINES. 

In hernias, these wounds are seen under two different condi- 
tions. First, where simple incisions are made by the cutting in- 
struments of an operator. If these be small, the muscular fibres 
speedily contract so as to approximate the several ends of the 
mucous membrane ; or if the incisions be larger, they may be- 
come rapidly agglutinized together by the lymph which is 
effused, or else the omentum may act as a plug. 

Secondly, where the ring has become constricted, and an ulcer 
has eaten its way through the intestinal walls. The loss of 
substance has here been so great that we can hardly hope for 
a closure without operative procedures. If the opening be longi- 
tudinal, and in the direction of the length of the intestines, it 
may be closed by suture, either the interrupted or the con- 
tinuous. If the opening be transverse, so that there is complete 
section, the ends may be united by invagination, by direct union 
or by circular ligature. 

Invaginaton. — In this method, Eandohr passed the superior 
end of the intestine into the inferior, and kept them in apposi- 
tion by a moderately tight suture, fastening the ends of the 




Fig. 65. — Jobert's Method. 



suture to the abdominal opening. A single suture is not suffi- 
cient. Not only, therefore, has the number of sutures been mul- 
tiplied, but to make contact more complete the intestine has 



WOUNDS OF THE INTESTINES. 311 

been surrounded by a cylinder of prepared card-board or some 
other unyielding material. Jobert invaginates the intestine and 
places the serous membrane back to back by first turning the 
end of the inferior portion inwards before passing the superior 
end into it. 

If the operation be successful, there remains in the inferior 
end a valve formed by the invagination of the superior end, 
which contracts the intestine at this point. 

Direct Union. — In this operation Eaybard has obtained the 
best results with an interrupted suture. By this method we 
get an annular constriction ; by Jobert's method this constriction 
is less, but still the formation of a valve makes the latter opera- 
tion less practicable. 

Denans caused direct union by joining the ends with three 
silver bands, but the presence of such foreign bodies is very ob- 
jectionable, and is enough to condemn the operation at once. 

Circular Ligature. — This is the operation proposed by Beclard, 
and was the one adopted by Amussat. The two ends of the 
intestine, being invaginated into each other, are tied and bound 
together by a strong band. The parts of the intestine which 
project beyond the ligature are then cut off with scissors. The 
two parts of the intestine are thus placed together by their 
serous surfaces, and the inflammation set up by the ligature 
causes adhesion. Experiments upon animals have shown that 
no contraction or constriction results from this operation. 

The peritoneal inflammation that may arise, and is likely to 
arise, from all these wounds or operations, is most successfully 
treated upon the general principles laid down upon pages 136 
and 139 of this volume. Maisonneuve's method of applying 
ice to the abdomen, as described on page 367, is a very excellent 
one, and one to be highly commended for practice. 



CHAPTEE XII. 

Trusses. 

I AM more and more convinced that so important a matter 
as the proper fitting of a truss has been most terribly over- 
looked by the medical and surgical profession, and that it should 
receive more careful and personal attention at their hands. 
Who in our profession if called to adjust a fractured limb would 
think of referring his patient to the care of the mere mechanic 
who may make splints or to the dealer who may vend them, and 
feel that he had done all that was necessary and right, or that 
could be expected of him ? If no surgeon would think of 
excusing such criminal conduct in the case of a fracture, which 
will heal with the most limited amount of surgical supervision, 
why should it be considered unprofessional to adjust the truss 
which may have to be worn for years or even for a lifetime, and 
which if improperly fitted may endanger life far more than pro- 
tect it ? Has not this very important matter been left altogether 
too long — to our shame be it said — in the control of the 
manufacturer and the vendor ? 

I feel confident that I do not draw an exaggerated picture 
when I say that many a patient when he has asked where or 
how to get a truss has been told by his medical adviser to " go 
to Mr. , druggist, who has them for sale, for as I was com- 
ing by his store this morning I saw some fine ones there made 
by a celebrated maker, I at this moment forget who, but you 

it 2 



TRUSSES. 313 

can easily find them, for the leather covering is stamped all over 
with bright gilt letters. I know you will get a good fit there, for 

Mr. used to be a cooper, and of course he is used to fitting 

any body or thing that needs hooping." 

Many are the patients that call upon me wearing barbarous 
appliances, that I certainly would not think of putting upon a 
brute animal. Let me give one instance. Last winter a poor 
deluded man came to me wearing a contrivance with four rollers 
similar to those used on parlour skates. These were applied as 
a pad to a spring, as stiff and hard as the hoop upon an oaken 
cask, and the whole was adjusted by heavy straps of stout 
leather around the body, and having the usual perineal attach- 
ment. It pressed so hard that I have often wondered how it 
was possible that the circulation could act in the large blood- 
vessels of the lower limb. More than all, it was a very imper- 
fect fit. The swollen and excoriated skin that these implements 
of torture produce in order, as the dealers say, to produce a 
radical cure will, I think, if my previous arguments have not 
been sufficient, show why I object to the term as applied 
to an exact and scientific surgical operation. The agony 
these poor sufferers endure is only helped along by the ex- 
treme delicacy which many of them feel to confess that they 
are afflicted with a disease, which for purposes of selfish and 
sordid gain the dealers in trusses often call an immoral disease. 
Immoral indeed ! Would that half the ills of mortals were as 
free from taint and immorality ! 

It will readily be understood that in this general condemna- 
tion I do not condemn those dealers in these articles who are 
known to be proper men with honest principles, and who endea- 
vour to fit a truss as the physician may direct. To such men, 
generally to be found, I should have no hesitation in recom- 
mending patients for a proper instrument (Fig. QQ). 

A properly fitting truss should combine lightness, strength, 



314 



HERNIA. 



and elasticity, so that it can be worn with grace and ease by the 
patient, and retain his hernia always within the proper place. 
The steel should be the finest, and as elastic as the mainspring of 
a watch (Fig. 67). Such a spring can be worn with ease, and is 
at the same time capable of exerting sufficient force to retain the 
hernia. A truss like this is now easily obtained from any of 
our first-class instrument makers, and no others should ever be 
recommended to be used. Such makers' firms are Codman and 





Fio. 66. — Proper position for Umbilical 
Truss. 



Fio. 67. — Proper position for Truss in 
Inguinal Hernia. 



Shurtleff, of Boston ; Tiemann and Co., of New York ; Milli- 
ken, of London; and Charriere, of Paris. Their styles are 
numerous, but for effective service the truss should be as 
plain and as little ornamented as possible. Instruments like 
these will usually not disappoint us in performing all that is 
recommended for them, and of course the patient is not endan- 
gered by the truss slipping or giving way should he jump or 
make any sudden movement of the body. It would be well if 
the patient could always have an extra one at hand, especially in 



TRUSSES. -315 

travelling, so that he may be forearmed in case of any possible 
emergency. 

For a few practical hints upon trusses, their various patterns, 
and their application, I refer to a paper written for this work by 
my friend Dr. Benj. S. Codman, of the firm of Codman and 
Shurtleff, and a gentleman whose experience in this matter we 
all highly value, from the fact that he has received a regular 
medical and surgical education, and has spent nearly a lifetime 
in the proper adjustment of trusses. 

"Human ingenuity has ever been taxed to its uttermost to 
invent a truss, supporter, or appliance, comfortably to restrain 
and hold this uncomfortable protuberance of the abdominal 
viscera. 

"In the great world's Exposition in Paris in 1867, in the 
' Surgical Department,' was to be seen a collection, both 
' ancient and modern/ of these appliances, which served well 
to mark the improvement that has been made in their manu- 
facture. Yet we must still look forward, as perfection has not 
yet been attained, and until it has, we must continue to use 
the best attainable substitute. 

" Which is the best truss ? Year after year the cry has been 
raised, ' T have found it ; ' and a new patent truss has been 
launched forth, with the promise of meeting every want, and 
being capable of curing the most obstinate cases of Hernia ; 
only too soon, alas, to disappoint this large class of suffering 
humanity with its utter failure, and only to see their fond 
hopes dashed to the ground. 

" Trusses are a necessity, and the surgeon should study to meet 
the want, and thoroughly to understand the anatomy of Hernia, 
so that he can recommend the most suitable instrument, and 
the proper person to make the application if he is unable to 
attend to it personally. 

" The best truss is the one best adapted to the case ; and when 



316' HERNIA. 

we say that, we mean that age, sex, and condition are to be 
considered. 

" Is it proper to apply a truss to a yery young infant with 
congenital Hernia ? Yes ; and the sooner the better, provided 
it is skilfully done, as the rings contract if properly supported, 
and the bowels enlarge, so as not to easily force through the 
inguinal or femoral openings (Fig. 68). 

" Trusses for infancy and childhood should be light, springy, 
and delicate. Children wearing napkins should have the pad 
constructed of black ebony or ivory, for the following reasons : 
such pads never change their form ; they are more durable, as 
a soft chamois-covered pad becomes wet with urine, and foetid, 

Fig. 68. 



Spiral Spring Pad. 

and falls to pieces in a few weeks ; and, better than all, the 
hard pad holds better, is smooth and less irritable, and in 
many cases will permanently close the rings, and obviate the 
necessity of a second truss. But to do this the case will re- 
quire careful watching on the part of both doctor and parents. 
If parents think a hard-pad is too hard, it may be safe to allow 
them to place beneath the pad a few layers of an old soft linen 
handkerchief, which can be changed as circumstances require. 

* The surgeon may direct to whom to go and the kind of truss 
best adapted to the case ; but after all, so much depends on the 
right application and nice adaptation that no one should be 
patronized or allowed to apply trusses but the most experienced ; 
Rnd if he has made this affliction a life study, and has had 



TRUSSES. 



31' 



the advantage of a medical and surgical education, so much the 
better for the patient. 

" The cuts in this work illustrate only a few of the many kinds 
of trusses, all of which have had their day as ' patent trusses/ 
but are now common property and subserve a general good 
purpose. (Fig. 69.) 



Fra. 69. 




Single French Style or Long Pad. 



" The French style of truss is a popular truss. It has a light 
elastic spring and a soft stuffed pad. It affords gentle but firm 
support to the hernial rings and the lateral muscles, and for 
persons of either sex advanced in life, or of delicate health, it 
serves an admirable purpose. It is strongly recommended for 

Fia. 70. 




Double French Style. 



wear after the operation by injection until the parts become 
firmly united. (Fig. 70.) 

" The Batch et truss is emphatically the working man's truss, 
for its construction, strength of spring, and its adaptability. It 
is the truss generally sold to the country druggist, because it 



318 HERNIA. 

meets more wants than any other, and because of its easy 
applicability. Discretion ought always to be used. 

"Take the case of a porter with a bad Scrotal Hernia, who has 
to shoulder a Saratoga trunk and carry it to the fourth story of 
a mammoth hotel. He must have a truss that will meet every 
demand of his case. The same is true of an express-man, ever 
handling heavy boxes and goods. (Fig. 71.) 

" The Ball and Socket truss has been for many years a popular 
truss, and will always take its place among the good appliances. 
It seems to be the happy medium between the French style and 
the Katchet truss. The ball and socket movement to the pad 
allows the truss to become self-adapting to any position of 

TV? 71. 




Double Spiral Spring Pad. 



the body, such as stooping, mounting a ladder, &c. It has a 
light flexible spring, is capable of good work, and gives great 
satisfaction to those who use it. 

" Umbilical trusses may be mentioned. We will begin with 
the treatment of infants. If our nurses were thoroughly edu- 
cated, and applied a suitable bandage at the first dressing, the 
truss-maker's services would rarely ever be needed. Light steel 
springs covered with soft leather, with a small convex pad, may 
serve a good purpose ; but we find a better substitute in a small 
flat pad (Fig. 72) a little larger than a silver dollar, with a 
small convexity in the centre. It should not be too convex or 
pointed, as that would tend to open rather than contract the 
orifice. It will give a gentle pressure like the human thumb, 



TRUSSES. 



319 



hold the Hernia, allow the ring to contract, and entirely cure 
the difficulty. This pad may have an elastic band passing 
round the body, with leather ends, to be secured to two small 
nobs on the front pad. Great care should be exercised in not 




Child's Umbilical Belt, elastic. 

stretching the elastic more than just enough to keep the appli- 
ance in its place (Fig. 73). In the adult we find the most dis- 
tressing cases of Umbilical Hernia in obese women, many of 
them the size of an infant's head. Steel spring trusses as a 
general thing do not meet these cases. The best thing for such 
cases is a wide French twilled drilling abdominal supporter, say 
eight or ten inches wide in front, to tit and support the entire 

Fia. 7a 




Adult Umbilical Truss. 

abdomen, passing around the body, and fastened on the sides 
with four elastic straps and buckles. The next step is to have 
a large centre pad, to suit the case, stretched to the inner side of 
the supporter. The pressure is controlled by the elastic side 
straps. 



320 HERNIA. 

" There are, of course, many good and useful kinds of trusses 
not mentioned. My object has been to point out a few only 
that can safely be relied upon. In cases of inguinal and fem- 
oral rupture, there is one principle necessary for a good truss ; 
viz., the inward and upward, or, in other words, the lifting 
power of the pad. As the inguinal and femoral rings are 
always above the pubic bone, the pads should be so adapted 
as to cover the rings securely, always above the bone. Al- 
though there may be some exceptions to this general rule, 
they are so rare that at this time we will not stop to mention 
them, as my sole object is to give a few practical hints how 
to meet a want or an emergency until the time shall come 
when all shall be convinced that surgery has provided in the 
cure by injecting the hernial rings a substitute for trusses and 
appliances, and until those who are afflicted shall come and be 
thus healed of their distressing malady." 

Bryant says " that in oblique inguinal hernia, the pad of the 
truss should be placed over the internal ring and canal, and not 
over the external ring, the object being to give support to the 
weak internal ring ; in direct inguinal, it is placed over the ex- 
ternal ring. In femoral hernia, when the crural arch is natural 
and not relaxed, a small pad may be employed over the neck of 
the sac ; but, when the arch is relaxed and movable, a large 
pad, so adjusted as to press on the ligament itself, is required. 
After the operation of herniotomy for crural hernia, this fact is 
worthy of attention ; for when a free division of Gimbernat's 
ligament has been made, the neck of the sac is always large 
and the ligaments relaxed." The improper adjustment of a 
truss, even if it has no other more serious consequences, may be 
one of the factors in the causation of varicocele. Hence the 
proper adjustment is a point worthy of the attention not only 
of the truss-maker, but of the surgeon himself. 

Ever since I began to operate for hernia by the method of 



TRUSSES. 



321 



subcutaneous injection, I have been troubled to obtain a proper 
and suitable truss to be worn by the patient. The trusses that 
have been in common use are constructed upon a plan that is 
entirely erroneous. They have a pad of wood or metal, stuffed 
with hair or some soft substance, and covered with leather. 
They are thus very heating and inconvenient to the patient, 
because they prevent the exhalation of moisture and perspira- 
tion from the body. 




Fig. 74. — Anatomical Truss. Anterior Aspect. 




Fig 75. —The same. Posterior Aspect. 

The convexity of the pad is also very objectionable, and is in 
direct antagonism to the anatomy of the parts to which the 
truss is applied. By its constant pressure, it has a marked ten- 
dency to dilate, weaken, and paralyze the rings, instead of con- 
tracting and strengthening them. Thus, in the course of time, 
the pad that has been worn is no longer sufficient to retain the 
hernia, is painful and even unendurable, and finally has to be 
thrown aside, and a larger pad applied. 



322 HERNIA. 

Eecognizing these deficiencies, I have devised a truss which, 
I think, will meet all the demands. (Figs. 74 and 75.) The pad 
is composed of a rim of hollow tubing, in sizes from No. 12 to 
No. 21, over which very fine wire gauze is tightly drawn, and 
soldered neatly and securely. The plane of the pad is slightly 
concave, in order to accommodate it to all the anatomical rela- 
tions, and can be still further adjusted by the surgeon to any 
individual case. The gauze being drawn tightly over this rim 
gives us a fiat pad, which presses upon the body like the human 
hand, the best of all trusses. The pad is soldered at its neck 
to the spring, and is so shaped that it will not press upon the 
spermatic cord in scrotal hernia, nor too hard upon Poupart's 
ligament in femoral. Neither will it glide over this ligament 
and slip into the groove of the groin, as does the common pad. 

There is a bridge of tubing over the pad, which serves to 
strengthen it, and may also assist in retaining in apposition to 
the body a sponge, either medicated or moistened simply with 
cold water, for the purpose of reducing inflammations. The 
pressure of the pad can be applied in any desired direction, for 
there are three knobs for the attachment of the strap. 

Between the pad and the integuments, a layer of cotton flan- 
nel, either single or double, should be placed ; this can be re- 
newed by the patient as often as desired. The perineal band 
consists of small gum-rubber tubing, or a coarsely braided silken 
cord. This will be found far more comfortable to the patient 
than the flat and sharp-edged strap, which soon cuts and 
chafes. * 

It will be evident to all that this is a very light and com- 
fortable truss. It is hygienic and is accurately fitted to the. 
parts. It is anatomical, because it tends to draw the pillars 
of the rings together rather than to separate them. Hence, even 
if used without the operation of injection, such a truss is better 
fitted to effect a cure of hernia than any convex pad in use. 



TRUSSES. 323 

This Anatomical Truss has been made, and all my ideas care- 
fully carried out, by Messrs. John Eeynders & Co., of New York. 
I can hardly conceive how a more beautiful spring could be 
manufactured ; it is equally elastic throughout its entire length. 
I do not know the secret of its manufacture ; but I half suspect 
a peculiar kind of steel is used, perhaps a combination of silver 
and steel. The tempering is perfect, and the spring has that 
peculiar elasticity imparted only by the magic hammer in the 
hand of the mechanic. 

The springs are of two degrees of stiffness. One is very 
soft and gentle in its action, and is adapted for use after the 
operation of subcutaneous injection. It can be applied in eight 
or ten days after the operation. The other is stronger, and is 
better adapted for all those forms of hernia where a truss is to 
be worn. It can be worn with perfect ease night and day with- 
out removal, as it is non-corroding, and is covered with the 
best grained or Eussia leather. 

I call the attention of the profession to this truss as the most 
practical one I have ever seen. It is the truss I should rec- 
ommend to those who are adopting the method of subcutaneous 
injection in their practice. It is of course free from all patent 
or trade mark ; but, in order that the profession may be sure 
of obtaining the very best, Messrs. Eeynders will number all 
that are made, and engrave their name upon them. This will 
be a guarantee of the excellence of the truss. 



CHAPTER XIII. 

Hydeocele and Varicocele. 

hydrocele. 

In the widest acceptation of the term, hydrocele signifies an 
accumulation of serous fluid in connection with either the testis 
or the spermatic cord. Hydrocele by infiltration is nothing but 
an oedema of the scrotum, while true hydrocele, or hydrocele by 
effusion, has its seat either in the cavity of the tunica vaginalis, 
or in cysts connected with either the testis or along the course 
of the cord. 

Hydrocele is therefore divided into Hydrocele of the Tunica 
Vaginalis Testis, and the Encysted forms in connection with either 
the testis or the cord. 

Hydrocele of the Tunica Vaginalis. — The accumulation of 
serous fluid in the tunica vaginalis may occur in two different 
conditions of the sac; either as the common form, when the 
vaginal process has become a closed sac, or as the congenital, 
when the tubular process of the peritoneum has never been 
obliterated, but remains in open communication with the peri- 
toneal cavity. 

Common Hydrocele. — This variety may arise because of either 
acute or chronic causes. Under the former may be classed acute 
orchitis or epididymitis ; but this is not the ordinary cause of 
hydrocele, because the fluid thus poured out is usually absorbed 
as the inflammation subsides. The ordinary hydrocele is a 
chronic disease without signs of inflammation in the testis, or 



HYDROCELE AND VARICOCELE. 325 

at the most, with only slight tenderness. It usually occurs in 
middle-aged persons, and without any evident exciting cause, 
although it may be developed by injury or severe muscular 
exertion. It results from a loss of balance between secretion 
and absorption. 

The disease begins with a swelling and sense of weight about 
the testis, which is either hard at the very beginning or at any 
rate soon becomes hard and tense. The accumulation of fluid 
begins at the bottom of the scrotum, as a tumor, oval or pyriform 
in shape, narrow above, broad and rounded below, smooth and 
tense, and with a semi-elastic feel. This tumor gradually en- 
larges and ascends up along the cord, but does not enlarge it, 
unless complicated by hydrocele of the cord. It never enters 
the external abdominal ring, although it may, when it reaches 
that point, cause such a deformity as to bury the penis out of 
sight, leaving only an irregular depression like that of the 

umbilicus. 

i 

The testis, as a general rule, is at the lower and hack part of 
the sac. It may be flattened and spread out by pressure, causing 
therefore an elongation of the epididymis and obliterating the 
pouch which normally exists between the testis and the epi- 
didymis. It may also be separated from the back part of the 
sac by an increase of this pouch, which then forms a second sac, 
or it may occasionally project into and transversely across the 
hydrocele sac to form a septum, or it may be so changed in 
position as to lie in the anterior portion of the sac, instead of in 
the posterior. All these variations should be borne in mind, 
in any given case, as possible complications. 

The serous fluid that is found, is simply an excess of the 
natural secretion of the cavity, or else it is this secretion slightly 
modified by inflammation. It is generally clear and limpid, and 
of a straw color. In old hydroceles, it may become brownish 
from disintegrated blood, or, rarely, it may be milky white. In 



326 HERNIA. 

either case, it is opaque rather than transparent. In composition, 
it is albuminous and alkaline, with occasional crystals of chole- 
sterin. The quantity varies, but averages less than a pint. The 
largest amount on record is that withdrawn by Mr. Cline from 
the historian Gibbon. This amount was six quarts ! 

The examination of hydrocele is simple, and is directed to 
three characteristics. First ; — the testis is found at the bottom 
and posterior portion of the scrotum. Second ; — there is a 
sense of fluctuation. Third; — the swelling is translucent. The 
last is the most positive sign, and may easily be determined by 
viewing the tumor through a roll of pasteboard, in contact with 
both it and the eye, in order to shut off all direct light and 
enable the surgeon to get only transmitted rays. The position 
of the testis is then recognized by a dark mass lying at the pos- 
terior part of the scrotum. 

This test is, however, not an infallible one, although it is 
usually sufficient for practical purposes. It may happen that 
the sac, which is generally thin, may have become dense and 
thick like pasteboard, or cartilaginous, or even osseous like the 
case reported on page 346. It may also be lined in some cases 
by a kind of false membrane, and occasionally may be divided 
into nearly distinct compartments by septa or bands, or even by 
the testis itself, as has been already mentioned. By conducting 
the test in a darkened room, however, it may be rendered avail- 
able, even in these cases. 

Hydrocele may be confounded with Scrotal Hernia, but is 
distinguished by its translucency, by its abrupt termination at 
the external abdominal rino- and its non-invasion of the inguinal 
ring, by the absence of impulse upon coughing, and by the his- 
tory of growth, whether proceeding from above downward, or 
from below upward. Other differentiations may be found in 
Table No. 3, page 80. Hydrocele and hernia are not infrequently 
co-existent, the hernial sac descending in front, behind, on one 



HYDROCELE AND VARICOCELE. 327 

side of, or into the sac of the Hydrocele. This was the case with 
Gibbon, who died from an irreducible hernia reaching to his 
knees. 

Hydrocele is distinguished from Cystic Disease of the Testis by 
the fluctuation being general instead of circumscribed; from 
hematocele, or collection of blood in the tunica vaginalis, by its 
translucency. When the hydrocele is non-translucent, the diag- 
nosis must be aided by the trocar. See Table No. L, page 78. 

Congenital Hydrocele. — Since there is an open communication 
between the tunica vaginalis and the peritoneal cavity in this 
variety, the serous fluid can easily be returned by pressure into 
the abdomen, especially in the recumbent position. The sac 
will then gradually refill, when pressure is removed or when 
the patient stands up. It thus differs from common hydrocele, 
but resembles hernia. It may be differentiated from the latter 
by its translucency, and from the " acquired " forms of hernia 
by the less perceptible evidence of the testis at the bottom of 
the scrotum. 

Encysted Hydrocele of Testis. — Here the fluid is not in the 
tunica vaginalis, but in a cyst projecting from the epididymis 
or the testis, and has pushed the serous covering of the gland 
before it. It differs from common hydrocele in being situated 
above, below, or to one side of the testis, instead of enveloping 
it. Curling has pointed out that these cysts, which are small 
and multiple, are more common on the epididymis than on the 
testis. They are very liable to rupture into the tunica vaginalis, 
and contain many spermatozoa, as was pointed out by Liston. 
This is probably due, according to Curling, to the " accidental 
rupture of a seminal duct into an already existing cyst." The 
tumor is both fluctuating and translucent. 

Hydrocele of the Cord. — This is characterized by the presence 
of a cyst containing serous fluid and situated on the cord near 
the testis, or within the inguinal canal and near the internal 



328 HERNIA. 

ring, or at any intermediate point. It is always distinct from 
both the testis and from the tunica vaginalis. It is elastic and 
translucent, and can be reduced into the abdomen, but receives 
no impulse on coughing and does not change size by compres- 
sion. When it lies in the inguinal canal, it is with great 
difficulty distinguished from inguinal hernia. See, however, 
Table No. 4, page 81. 

It seems to be formed by the incomplete obliteration of the 
funicular portion of the vaginal process of peritoneum ; or it 
may be a distinct cystic growth. It is most frequent in children 
or young boys, although it may occur at all ages. 

Diffused Hydrocele of the Cord. — This term has been used by 
Pott and by Scarpa, but it signifies only an oedema of the cord 
and not a cystic formation. Its treatment is on general prin- 
ciples ; usually by counter irritation with blisters, or with 
external applications of iodine, until desquamation is produced, 
or even with mercurial ointments in simple cases. 

Operations by Hydrocele. — The treatment of hydrocele is 
either palliative by tapping, or curative (sometimes called radical) 
by tapping, and afterward exciting inflammatory processes within 
the sac. 

Palliative Treatment. — A few precautions are necessary to 
avoid injuring the testis or puncturing the scrotal veins. The 
scrotum being held in the surgeon's left hand (or in the hand of 
an assistant), and put upon the stretch, the trocar is plunged 
into the tumor a little below its middle. (Fig. 76.) The trocar 
should be introduced boldly, so as to penetrate the tunica vagin- 
alis and not permit the instrument to slip into the areolar tissue 
between the skin and tunica vaginalis. Inattention to this point 
may lead to infiltration and sloughing of the scrotum. The direc- 
tion of the puncture should therefore be at first directly back ; 
but, as soon as the sac is perforated, the trocar should be directed 
upward so as to avoid the testis. (Fig. 77.) 



HYDROCELE AND VARICOCELE. 



329 





Fig. 77. — Direction of trocar in making 
the puncture. 



Fig. 76. — Puncture of Hydrocele. 

I use as small a trocar as it is possible to get, and in the 
majority of my cases I find my spiral aspirating needle (figured 
on page 216) the best. 

The trocar being withdrawn, if one has been used, the fluid is 
evacuated through the canula, and the puncture spot, if neces- 
sary, covered with a piece of adhesive plaster. The relief thus 
obtained is, however, only temporary, and the sac may gradually 
refill and demand another tapping. 

Curative Treatment — This method seeks to excite an inflam- 
matory action within the sac after the fluid has been withdrawn. 
Whether this inflammatory process is for the purpose of creating 
adhesions between the two walls of the tunica vaginalis, or for 
the purpose of restoring a functional equilibrium, will be later 
discussed. At any rate, it is a well-known fact that methods 
which have been very successful will sometimes fail, and that 



330 HERNIA. 

then successful treatment will often require the exercise of the 
greatest ingenuity of the surgeon. 

Seton. — This method, although formerly much used, is rarely 
employed at the present day because of the danger of exciting 
too serious inflammation. It is performed by inserting a few 
strands of silk into the sac after the fluid has been withdrawn. 
The silk is usually removed after about thirty hours. Silver or 
iron wire have been proposed as setons. 

Incision. — With the patient under ether, the tumor is opened 
from above downward and charpie or lint placed in the cavity to 
excite irritation and suppuration. This is a method that has 
been used since the time of Celsus and Guy de Chauliac, but the 
pain and accidents that result from it, as well as from the method 
of excision, would seem enough to render caution advisable in 
such procedures, especially in view of the fact that simpler 
operations are at hand. 

The German " Schnitt " method has, however, been performed 
this present year three times by Mr. Joseph Lister, F.R.S., with 
antiseptic precautions, at King's College Hospital. The bleeding 
points were ligated and the sac stitched to the skin with cat- 
gut, but the wound left unclosed. The cases were reported 
cured after a period varying from two to three weeks. 

The chief point of interest in the last case was the total 
absence of all irritation of the skin of the scrotum. " This irri- 
tation had been a distressing symptom in the two earlier cases, 
in which carbolic dressings had been used ; but the new eucalyp- 
tus gauze dressing was entirely free from this inconvenience. 
The scrotal skin being extremely sensitive to the action of irri- 
tants, this was a good test of the non-irritant qualities of the 
gauze ; its antiseptic qualities were also severely tested and were 
not found wanting." 

Another antiseptic preparation, which is said to be many 
times more powerful and much less harmless than carbolic acid, 



HYDROCELE AND VARICOCELE. 331 

is a combination of principles extracted from thyme, eucalyptus, 
baptisia, gaultheria, and mentha arvensis, together with benso- 
boracic acid. Time and experience will show the comparative 
merits of these various antiseptics. 

Excision. — The incision into the scrotum being made as 
above described, a portion of the tunica vaginalis is removed 
with the scissors or knife and the wound allowed to heal under 
the water dressing. It has been in use from very early times 
and has been variously modified, but since it is painful and not 
to be depended upon with any degree of certainty, it is another 
of the methods to be tried only after the method of injection has 
failed. 

Injection. — This is no new treatment of hydrocele, since Cel- 
sus in his day advised the surgeon to inject solutions of nitre 
or saltpetre into the sac after it had been emptied. It did not, 
however, get into general practice in either England or France 
until after the memoir of Sabatier. 

Different fluids have at different times been injected. Lem- 
bert used lime-water charged with corrosive sublimate and in- 
jected it also through the same canula by which the serum had 
been withdrawn. Eed wine, port wine, and pure alcohol have 
all been tried and are even now used in combination. Leveret 
used a solution of caustic potash. Bertrandi and Cooper were 
very successful with sulphate of zinc, in the proportion of a 
drachm to the pint of water. Velpeau once used spirits of 
camphor with success. Beclard used cold water, while milk, 
the serum of the hydrocele itself, solutions of salt, of alum, of 
tannin, and of iodine have all been tried with more or less 
success. 

The operation, too, has been performed in various ways. 
Some have injected large quantities of fluid, and others only a 
small amount. Some have allowed the injection to remain in 
the sac, while others have allowed it to escape after the lapse of 
a short period, varying from a few minutes to a half hour. 



332 HERNIA. 

The injection is usually made through the *same canula by 
which the serum has been withdrawn. After injecting an 
amount of fluid sufficient to distend the sac to the size it had 
before it was tapped, the syringe is withdrawn and the open 
end of the canula plugged for a few minutes by the end of the 
thumb. It is preferable then to evacuate the fluid from the sac. 

Three practical points should never be lost sight of in per- 
forming the operation. In the first place, the canula should be 
known to be within the cavity of the tunica vaginalis before 
any injection is attempted. In the second place, care must be 
taken that when the patient cringes, as he probably will at the 
moment of injection, the canula be not displaced or withdrawn 
so that some of the fluid can escape into the cellular tissue of 
the scrotum and cause a diffuse inflammation or even a slough, 
Finally, when the canula is being withdrawn, the sac should be 
nipped between the finger and thumb, to prevent this same 
infiltration. 

A small piece of adhesive plaster will be sufficient to close 
the puncture that has been made. Sometimes, after the injec- 
tion, the scrotum is covered with compresses soaked in the com- 
pound tincture of iodine, but in general it is fully as well to 
allow the scrotum to be free or at most to suspend it in a band- 
age after the first day. The cure is usually complete in about 
fifteen days, although sometimes suppuration sets in and pro- 
longs the treatment. One injection is generally sufficient. 

Iodine is the fluid now almost universally used for injection, 
although I have no doubt that the fluid extract of oak bark or a 
solution of the sulphate of zinc would be effectual. I have 
never tried them. My favorite injecting fluid has been for 
years the officinal ethereal tincture of iodine reduced one half 
with water. The use of iodine was first introduced into practice 
by Mr. Martin at Calcutta, and we have already seen, on page 
128, that Velpeau was led by the practice of injecting hydrocele 



HYDROCELE AND VARICOCELE. 333 

with iodine to consider the possibility of curing hernia by in- 
jecting the hernial sac with the same fluid. 

Mr. Martin estimated that in India the failures by the opera- 
tion did not amount to one per cent, while Velpeau calculated 
them in France at three per cent. The explanation of the cure 
seems to offer a choice between two theories ; either an adhesive 
inflammation is set up which obliterates the cavity of the tunica 
vaginalis, or else the membrane is inflamed to the degree neces- 
sary to restore the natural equilibrium between secretion and 
absorption. 

Erichsen states his belief that it is a well-known fact that a 
cure by injection is not obtained by causing an obliteration of 
the sac of the tunica vaginalis, but by restoring the functional 
equilibrium. He therefore would offer, as one cause of failure, 
an insufficient inflammation to bring about this result. Another 
cause, he thinks, is, that from the inflammation that is set up, 
an effusion takes place into the sac which is not absorbed, but 
which serves to distend the cavity of the tunica vaginalis. 

Both of the arguments offered by this surgeon seem some- 
what probable from some clinical facts that are at hand. I once 
treated an enormous hydrocele that reached nearly to the knees, 
and which yielded about three quarts of straw-colored fluid on 
tapping. A silver probe with not more than one eighth or one 
quarter of a grain of biniodide of mercury in dry powder upon 
its moistened tip was now passed through the canula and thor- 
oughly swept around, the tunica vaginalis. Two rolls of cloth, 
one on either side of the testis and a little in front of it so that 
the three elastic bands which held them in place might not 
compress the gland, were used as compresses to the sac. With 
this simple dressing, the patient was cured at the end of about 
fifteen days. The inflammation was active, but not very pain- 
ful ; not nearly so painful as when I have injected iodine. 

Whether the application of the mercury, or the pressure of the 



334 HERNIA. 

compresses were the important factors in the cure of this case 
must yet remain a disputed point. I remember another hydro- 
cele that was very interesting to me several years ago. A 
young man was subject to intermittent attacks of effusion into 
the tunica vaginalis. The fluid would appear to the apparent 
amount of six or eight ounces, and then would disappear as mys- 
teriously as it came. This would seem to favor the theory that 
a disturbance of function is the cause of hydrocele. I had fre- 
quently relieved old cases of gonorrhoea by painting the under 
portions of the glans penis with a strong solution of iodine ; so 
in this case I thought of painting the entire scrotum in a simi- 
lar way. I did this until desquamation was produced. The re- 
sult was a cure. The success of the treatment may, in the 
minds of some, seem to strengthen the theory under discussion. 

I have also treated cases by allowing the fluid to ooze through 
a fine aspirating needle, and then painting the scrotum with a 
strong solution of carbolic acid in several places. I then insert 
into a cork three small sail needles with triangular points, and 
tattoo those parts of the scrotum that I have painted ; the acid 
seems to paralyze temporarily the sensitive nerves of the skin. 
With the after-treatment of compression, this method will often 
prove successful in youth and in cases of short duration Then 
again, I have found, in many cases, that, by irritating the walls 
of the sac as I withdraw my needle and by only slightly com- 
pressing them, I have gained very satisfactory results. 

On the other hand, it is the theory generally accepted that 
compression of the sac, or, at any rate, adhesive inflammation set 
up upon the walls of the sac, are necessary to secure a cure, 
and it is this theory that suggested the Curative Method of 
operation. So that the best we can do at present is to leave the 
matter an open question, and not decide in toto with either 
party in the strife. In some cases, a cure seems to be produced 
by adherences in the walls of the sac, in other cases, by a modi- 



HYDROCELE AND VARICOCELE. 335 

fication of function, and in others, by a combination of both 
processes. We all know, too, that there, are cases which do not 
yield to one method, but that seem to yield to another, and that 
finally there are cases which seem to yield to no usual operation, 
but baffle all attempts at remedy, except the more severe opera- 
tion of excision of the sac. Cases of long standing that have 
much perplexed the surgeon have also been known to recover 
fully after being freely opened with an ordinary thumb lancet 
and allowed to heal by granulation. 

VARICOCELE. 

This enlarged condition of the spermatic veins is commonly 
met in young persons from puberty to the age of thirty. It is 
sometimes known as cirsoccle and also as spermatocele. It 
usually occurs in persons who have the scrotum loose and 
pendulous. 

The left spermatic veins are much more frequently varicose 
than the right, partly because of the pressure of faeces in the 
sigmoid flexure, and partly because of the fact that the veins on 
the left enter the renal vein at a right angle, while those on the 
right enter directly into the inferior vena cava. Brinton offers 
as an explanation, " the existence of a very perfect valve that he 
discovered at the entrance of the right spermatic vein into the 
vena cava, which thus supports the column of blood on the right 
testis, while there is no valve at the termination of the left 
spermatic in the renal vein." 

The causes of this varix are both predisposing and exciting. 
Under the former may be classed the tortuous anatomical struc- 
ture (plexus pampiniformis) and loose surroundings in the 
scrotum ; under the latter, any exertion which affects these 
veins, such as long-continued walking or straining at stool. 
It is sometimes the case also that venereal excesses, or on the 
other hand extreme continence, may be exciting causes. Since the 



336 HERNIA. 

improper application of a truss may have an influence in causing 
a varicocele to appear, the reader is referred to page 320 for 
direction in regard to the proper adjustment of such a support. 

The symptoms of varicocele consist of a tumor, knobbed and 
convoluted, feeling to the touch like a bundle of earth-worms. It 
is inelastic and compressible, diminishes slowly in the recum- 
bent position, and sometimes gives a slight impulse on coughing. 
Often the swollen veins can be seen through the thin scrotum. 
There is usually little or no pain, but there is a sense of tension 
and weight when the patient is standing. The testis undergoes 
a certain amount of atrophy, so that it may even be concealed 
beneath the mass of dilated veins. 

Varicocele is liable to be confounded only with scrotal hernia, 
but can readily be differentiated from it by Table I., on page 78. 

Operations. — The treatment is either palliative or curative, as 
in hydrocele. The necessity for operative interference must 
depend upon the individual case, whether the pain and inconve- 
nience be unsupportable, or the testis atrophying, or the geueral 
health failing and the person suffering from mental disquietude 
and hypochondriasis. The patient often thinks constantly of 
copulation, but is fearful that he is losing his virile powers. 
A few words of explanation and encouragement from the physi- 
cian will often do much to dispel such gloomy forebodings. 
When the varicocele is due to engorgement of the testis, the 
stimulus of occasional sexual intercourse has been recommended 
to relieve it. 

Palliative treatment consists in supporting the varicocele in a 
suspensory bandage or an elastic bag. Mr. Curling has recom- 
mended a truss bearing upon the external ring, with the idea of 
preventing any efflux of blood into the veins during any sudden 
exertion. In some cases, support may be given by drawing the 
scrotum through a ring of metal covered with soft leather, and 
by this means suspending it. 



HYDROCELE AND VARICOCELE. 



337 



Curative treatment consists in the obliteration of the enlarged 
veins by compressing them, and thereby exciting inflammation. 
For this purpose, the ancients used the cautery, but in more 
modern times the following plans have been proposed : compres- 
sion with forceps, compression with hare-lip pins and the twisted 
suture, subcutaneous compression between a pin and wire, liga- 
ture, and subcutaneous ligature. 

Breschefs Operation. — This produces a slough by clamping, 
in a pair of forceps, a fold of the scrotum in which the dilated 
veins are included. After forty-eight hours or less, the parts 
will have become a dry eschar which is soon followed by an 
ulcer and cicatrix. 

There are many modifications of this method, prominent 
among which is the plan of Landouzy. This consists in using a 
pair of forceps which shall not compress the fold of skin, so 
that, after the sloughing of the eschar, a sort of cutaneous bridge 
is left. 



C.S.E 




•-w 



Fig. 78.— Rigaud's method in Varicocele, C.S.P. Spermatic cord, V.V. Varicose veins under 

which is passed the tape. 

Velpeaiis Operation. — In this method pins are used in place 
of forceps. Over these pins a figure of 8 suture is passed so 



338 HERNIA. 

as to include the veins and a fold of skin. As, however, erysi- 
pelatous inflammation was liable to follow, the operation was 
subsequently modified and made essentially like Pancoast's 
earlier method, which will be described on a later page. 

Simple Isolation. — Eigaud's method. An incision is made 
through the skin for the greater part of the length of the scrotal 
sac and a tape passed beneath the mass of veins. The wound is 
then dressed with lint until suppuration is set up and the vas- 
cular mass mummified. This takes place by the third day. 

Ligation. — This was the operation of Celsus. A vertical 
incision of nearly an inch is made in the scrotum over the tumor 
of veins. The vas deferens, artery, and nerves are then, as in 
all the operations, separated from the veins. Under the latter a 
straight needle is passed and a stout thread twisted around it in 
the form of the figure of 8 so as to compress them. After five or 
six days the patient may sit up, and after as many more he may 
walk about. Cold-water dressings are the best to be used. 

Intermediate Ligature. — Eaynaud's method. The veins are 
taken up with a fold of the skin and a thread passed under them 
by means of a curved needle. The ligature is then tied over the 
skin, which is afterwards divided with the bistoury. The liga- 
ture is tightened every day until the veins are divided ; this 
usually takes place in fifteen or eighteen days. 

Subcutaneous Ligature. — Gagnebe's method. The ligature is 
passed under the vessels by a curved needle and then above and 
over them, the needle making its exit from the skin at the point 
of puncture. The objection to the method is that the ligature 
cannot be easily tightened, and that therefore section of the 
veins takes place slowly. 

Malgaigne therefore ties the ends over a roll of diachylon on 
the end of a probe. Erichsen has further modified the operation 
by using silver wire, which can be twisted to gain any desired 
degree of compression. 



HYDROCELE AND VARICOCELE. 339 

Ricord's Method. — This is a modification of Gagnebe's opera- 
tion. A double thread is passed behind the veins and out 
through the scrotum. Another double thread is passed in front 
of the veins and through the punctures that have been already 
made. By passing the free ends of each ligature through the 
opposite loops and drawing upon them, the veins will be con- 
stricted. Formerly the free ends were then wound over a sort 
of tourniquet, but later M. Eicord found that mere traction with- 
out ligation would be equally effective. 

Pancoasfs Method. — This operation is a modification of 
Eicord's, and seeks to strangulate the veins by means of a 
straight needle and double ligature. Formerly he passed the 
ligature behind the veins, between them and the duct, but in- 
serted the needle in front of the veins, between them and the 
skin. The loop of the thread was then thrown over one end of 
the needle, and the free ends tied upon the other extremity of 
the needle. 

Later, Dr. Pancoast passed the needle, threaded with a strong 
silken cord, between the veins and the duct, and repassed it in 
front of the veins and out at the point of puncture. The free 
ends were then tied over an ivory plate upon the scrotum. This 
is essentially the same method as that of Malgaigne, already 
mentioned. 

Operation of Vidal de Cassis. — This combines the subcu- 
taneous ligature of the veins together with a diminution of their 
length. A pin is inserted behind the veins and then a silver 
wire is passed in front of them, but through the same punc- 
tures by which the pin was inserted. The ends of the wire are 
then twisted over the pin, and every day the pin is rolled up so 
as to twist another turn or two of the wire around it. 

Authors Operation. — My method of operation is extremely 
simple, but I do not claim that there is anything in it original 
with me, since it was performed by many other medical gentle- 
men before I ever attempted it. 



340 HERNIA. 



About three-quarters of an inch below the roots of the penis, 
and immediately over the veins, a vertical incision one half-inch 
in length is made. For this I generally use the demonstrator's 




Fig. 79. — Demonstrator's Knife. 

knife, which is the device of my son, Mr. Charles E. "Warren, 
Student in Medicine. In opening the sheath of the veins, a 
drachm of serous fluid, which has exuded from the varices, often 
escapes. 

After separating the veins from the cord and arteries by gently 
rolling the mass between the thumb and finger, the un sharpened 
curved end of the knife is passed beneath them and raises them 
up through the incision. About an inch from the tip of this 
blunt end is an eyelet, through which a stout silver wire has 
previously been threaded ; so that, as the bundle of veins lies in 
the curvature, the wire lies fully under and projects beyond 
them. 

The wire is then drawn over them and twisted or tied. The 
ends are cut short and pressed down, so that they may not cause 
irritation, and the veins allowed to fall back into the scrotum. 
The incision is then secured by a strip of adhesive plaster. 

A second incision is made about an inch below our first one, 
or at least below the enlarged veins. The process of ligation is 
the same as before. After this operation, a suspensory handker- 
chief is all that is necessary. Should swelling occur, applications 
of cold water, or of lead lotion with laudanum, are very useful. 

In the course of eight or ten days the swelling will subside. 
It will then be found that between our ligatures an effusion of 
plasma has solidified the veins. They will subsequently atrophy 
to a mere shred. The sutures are allowed to remain in position 
and never cause any trouble. The method may almost be called 
subcutaneous, since our incisions are so small that they readily 
coapt and cause little loss of blood. 



CHAPTER XIV. 

Observations on Heenia. 

It may be fitting, in this place, to give a few words of explanation in regard to 
the apparently heterogeneous character of the present chapter. Since the publi- 
cation of the first edition of this book, many points of detail and several new 
operations have been brought to the author's attention. Some of these suggestions 
are of prime importance and great value, while all of them are as much a part 
of the body of the book, and belong as properly to it, as though they had been 
published in the first edition. They do not in any sense belong to an appendix, 
which is often only a collection of points of minor importance, and therefore not 
worthy of a dignified position in the body of the book. 

The book had been, however, already stereotyped both in England and in America. 
In order, therefore, to use a portion of these plates, as far as practicable, con- 
sistent with a thorough remodelling and revision of the whole work, it has been 
thought better, by all means, to mass all such additions and new operations into 
a separate chapter, with appropriate references to the matter that had been already 
written, rather than to throw them into an appendix. 

1 Page 42. 

Because of the difficulties in diagnosis, Heister wished that 
inguinal could be distinguished from femoral hernia by the 
terms internal and external inguinal, since both varieties occupy, 
in an extended sense, the inguinal region. This, however, would 
be merely a change in terms, and would serve only to confuse 
more thoroughly the whole classification. See page 33. Sir 
Astley Cooper thought the diagnosis could be made by consider- 
ing the relation of the neck of the sac to the spine of the pubes, 
"the sac of inguinal hernia being placed above, while that of 
femoral is below, and to the iliac side of the spine." But this 
is not a conclusive test, since a relaxation of the inferior pillar 



342 HERNIA. 

of the ring, or a deficient development of the intercolumnar 
fibres, occasionally allows an inguinal hernia to assume this 
same position. 

It has also been supposed that all hernise above a line drawn 
from the spine of the ilium to the spine of the pubes are in- 
guinal, while those below are femoral. But Poupart's ligament, 
which this line is supposed to represent, does not actually de- 
scribe a straight line, and is so much relaxed and curved down- 
wards, particularly in women who have borne children, that it 
actually allows many inguinal herniae to be situated below this 
imaginary line. 

Malgaigne proposes a plan for making a certain diagnosis in 
such difficult cases where Poupart's ligament is relaxed and 
defies detection, and where the tumor recedes so suddenly on 
pressure as to render it impossible to tell the point at which it 
disappeared. 

His directions are as follows : " Eeduce the hernia, feel with 
the right forefinger the pulsations of the femoral artery, and, 
applying the pulp of the finger on the pubic side of the artery, 
press backward toward the pubes. Sometimes in thin persons 
you will feel the femoral ring open, bounded in front by Pou- 
part's ligament, behind by the pubes, on the iliac side by the 
vein and artery, the pulsations of the latter being felt through 
the interposed coats of the vein on the side of the finger ; then 
it is unnecessary to proceed further. In the natural state the 
finger never could thus penetrate into the femoral ring. But 
suppose the subject to be fat, the hernia small, and the ring too 
deep and narrow to admit the finger, you must press against the 
pubes whilst you perceive the pulsations of the artery against 
the side of the finger, and cause the patient to cough. 

" If the impulse is felt by the finger, and the hernia does not 
escape, it is femoral ; but if the impulse is not perceived and the 
hernia escapes above, it is inguinal. Occasionally an inguinal 



OBSERVATIONS AND OPERATIONS. 343 

hernia escapes above, and at the same time communicates an 
impulse to the finger. This effect can result only from one of 
the two following causes : either it is an inguinal hernia which 
distends the inguinal canal and transmits an impulse below Pou- 
part's ligament, or else the hernia is femoral, and has distended 
and pushed forward Poupart's ligament and a portion of the 
aponeurosis of the external oblique, so as to cause a projection 
above the ring which you have obstructed. You then with the 
right forefinger close the femoral ring, and having placed the left 
thumb transversely about three lines above it, cause the patient 
to cough, whilst you slowly withdraw the forefinger. If the 
hernia be inguinal, it is thereby retained ; if femoral, it pro- 
trudes." 

It has long been known to surgeons, that persons often live 
for years affected by a femoral hernia which had escaped all 
notice. The formation of such an incipient hernia has been 
already mentioned on page 35. For the method of diagnosing 
the hernia in this early stage we are indebted to Malgaigne. 
His rule is to place the pulp of the forefinger firmly on the 
pubic side of the femoral artery, and just below Poupart's liga- 
ment. The patient is now made to cough, and if a hernia 
exists the finger will receive an impulse. This impulse here is 
never normal. 

These directions are applicable only to reducible hernia?. If 
the hernia has become irreducible, the surgeon must endeavor to 
trace the neck of the sac. This can be most effectually done 
whenever Poupart's ligament cannot be satisfactorily traced over 
the tumor, by pushing the hernia upward and pressing with the 
pulp of the forefinger in the direction of the femoral aperture. 
" If the hernia be femoral, more especially if it be strangulated, 
a firm, resisting, and sometimes painful substance will be found 
occupying the femoral ring, and preventing Poupart's ligament 
from being felt." 



344 HERNIA. 



2 Page 42. 



Gastrocele, or more commonly epigastrocele, is a name ap- 
plied to a hernia occurring toward the upper part of the linea 
alba, or in the epigastric region, whether formed or not by the 
stomach. Its existence has been doubted by many. 

3 Page 42. 

Hepatocele. Probably increase of the bulk of the liver or 
injuries of the abdominal parietes are the cause of the protru- 
sions occasionally met with in those infants in whom the upper 
part of the linea alba is very weak. The liver has never been 
found entirely out of the abdominal cavity. Sauvages distin- 
guishes two kinds of hepatocele, — the ventral, i. e. in the linea 
alba, and the umbilical. 

4 Page 42. 

Cystocele is rarely congenital, but results from violent exer- 
tion, injuries, excessive straining in micturition, and occasionally 
follows pregnancy. In its simplest form, it is a mere protrusion 
of the mucous membrane through the urethra. This may even 
increase to a prolapse of the bladder. In other cases, the bladder 
prolapses at one of the usual seats of hernia ; in the male more 
frequently through the inguinal ring, and in the female under 
the femoral arch, in consequence of the different size of these 
apertures in the two sexes. In these cases, adhesions occasion- 
ally form between the bladder, viscera, and the sac. The flow of 
urine may be thus impeded, causing cystitis, calculi, or even 
septicaemia. Very rarely the prolapsed portion of the bladder 
may become strangulated. When the urine is retained, the 
catheter may aid in diagnosis. In very rare cases, herniotomy 
may be necessary to relieve the strangulation. 



OBSERVATIONS AND OPERATIONS. 345 

5 Page 43. 

Irreducible hernia may be caused by enlargement of the 
omentum or mesentery, as, for example, by an accumulation of 
fat. Adhesions between the sac and its contents, or adhesion 
of the neck of the sac from inflammation, blows, etc., may often 
produce the same result, with either contraction of the neck or 
hour-glass contraction of the sac. 

6 Page 43. 

An incarcerated hernia may be caused by an accumulation of 
fseculent matter or flatus in the fold of protruding intestine. This 
attack is often preceded by constipation or the swallowing of 
hard and indigestible food. It is most common in elderly per- 
sons with large abdominal cavities. 

7 Page 43. 

Strangulation occurs in two distinct forms of hernia, — in the 
old and long-standing, and in the newly formed. Distention of 
a pre-existing p rotrusion by faeces, etc., or by venous congestion, 
may also occasionally act as a cause. Spasm, which was formerly 
regarded as a cause, can have little, if any, effect in the causation, 
since the hernial orifices are tendinous or ligamentous, not mus- 
cular, and hence can be subject to muscular contractions only 
indirectly. 

8 Page 44. 

The following statement has been obtained by Dr. John L. 
Sullivan, in his examination of men for the military service in 
the late War of the Rebellion : — 

Number of men examined, 10,000 

Number rejected for hernise, 455 

or 45.5 per 1000 



346 HERNIA. 

Varieties. Femoral hernia, — Right, .... 1 

Double, ... 1 

— 2 

Umbilical, . 6 

Ventral, 9 

Inguinal, — Right, 234 

Left, ...... 173 

Double, 31 



438 



455 
The rarity of femoral hernia, not merely in comparison with 
inguinal hernia, but with the other and less frequent forms, is 
very striking. It is also worthy of note that the right is the 
affected side in very nearly two thirds of the cases of inguinal 
hernia. It will be seen that the proportion of persons with a 
hernia is nearly one in every twenty. This is about the esti- 
mate made by authorities who base their calculation upon the 
total population. 

9 Page 73. 

According to Sir Astley Cooper, the peritoneum, in forming a 
common hernial sac, " is not dragged from its natural position, 
but becomes elongated by gradual distention ; and it is usually 
not only lengthened but slightly thickened, for a long-continued 
pressure of moderate force will produce an elongation and thick- 
ening of fibre, though a greater degree will bring about an entire 
absorption of parts." 

10 Page 73. 

In this connection the following case of Double Hernia with 
Ossified Tunica Vaginalis, together with the operation and cure, 
performed and reported by Dr. H. S. Greeno, of Kansas City, 
Missouri, may prove of interest to the profession : — 

Eev. Mr. H , aged sixty-six, residence Lyon Co., Kansas, 

presented himself for treatment for radical cure of double rup- 



OBSERVATIONS AND OPERATIONS. 347 

ture, October 13th, 1880. I found upon examination an oblique 
inguinal hernia of the right side, of thirty-five years' standing, 
which had become scrotal, and an oblique inguinal hernia of the 
left side, of fifteen years' standing. The tumor of the left side 
was quite small, the bowel being easily retained by a truss. The 
external ring of the right side was very large in size, about two 
inches by one. The opening was so large that it was impossible 
to apply any truss that would retain the bowel within the ab- 
dominal cavity ; this gave him much pain and annoyance. He 
could stand upon his feet but a short time before being com- 
pelled to sit or lie down. I discovered one very serious obstacle 
which rendered an operation for radical cure very difficult, if 
not impossible. The right testicle was enormously enlarged, 
measuring about thirteen inches in circumference, and weighing 
over one and a half pounds. The weight of the organ would 
interfere with an attempt to occlude the rings by the Heatonian 
plan of treatment. The patient informed me that this testicle 
had been enlarged as "long as he could remember." From his 
earliest recollections the right side was the largest, and continued 
to enlarge until some twenty-five years ago, when it seemed to 
become stationary ; never gave him any pain, but was a great 
source of annoyance. After considering the case, and consulting 
with several of the profession, who examined the case with me, 
I concluded to remove the enlarged testicle, and, if successful, to 
attempt an operation for the radical cure of the hernia. Accord- 
ingly, on the 18th of October, in company and with the assist- 
ance of Drs. Cooly, Lewis, Dearrit, and Derrey, I removed the 
enlarged testicle. 

Now comes the most interesting part of the case. Upon 
examination it was found that the tunica vaginalis had become 
thickened and almost perfectly ossified, in some places cartilagi- 
nous. The osseous formation was quite perfect, and quite as 
solid as ordinary bone. It formed a complete shell, and con- 



348 HEENIA. 

tained within its cavity twelve ounces of pus. No traces of 
the testicle or epididymis could be found within the ossified 
tunica. 

The spermatic cord and vas deferens were entirely absent 
within the cavity. How long this pus had been confined within 
the cavity of the tunica is a question, — doubtless for years. I 
do not remember ever to have seen in any of our text-books or 
journals a case similar to the above. 

The operation proved successful, notwithstanding the age of 
the patient being greatly against him. He made a good recov- 
ery, and on the 2d of November, fifteen days from the time of 
removing the diseased testicle, I operated for radical cure of his 
rupture of the right side, using the Heatoniau operation, as 
modified and improved by Dr. Joseph H. Warren, of Boston. 
This operation was also a success, and on the 12th of November 
I allowed my patient to return to his home in Kansas. I con- 
cluded not to operate on the left hernia, as it gave him but little 
trouble, and was easily retained by the proper adjustment of a 
light truss. 

Under date of May 15th, 1881, Dr. Greeno writes to the 
author that this gentleman " returned to Kansas City in April 
last, and submitted to an operation for the cure of the left side ; 
so that he is now cured of both hernise." 

11 Pages 75 and 87. 

Symptoms Simulating Strangulation in Inflammation of Empty 
Hernial Sacs. — At a meeting of the Vienna Physicians' Society 
(Mittheil. des Wiener Med. Doct. Colleg., vol. vi., No. 26, Decem- 
ber 2, 1880), Dr. Englisch read a paper with the above title. 
Forty cases had been collected, and in thirty herniotomy had 
been performed. His own experience extended to six cases, of 
which number, four had concerned women. In the latter cases 
femoral hernia was observed exclusively. If, in consequence of 



OBSERVATIONS AND OPERATIONS. 349 

some irritation or traumatism, the peritoneum of the sac became 
inflamed, symptoms of strangulation would be developed, even 
if the sac had no intestinal or omental contents. The protru- 
sion would first of all become exquisitely painful, rapidly in- 
crease in size, and become tense. In some few instances the 
augmentation in volume had been slow. 

The quality and extent of the pain might aid differential 
diagnosis, without, however, being so characteristic as to exclude 
the possibility of error. In actual strangulation, the most in- 
tense pain would be felt at the constricting ring, and thence 
extend into the abdomen. If an empty sac became inflamed, 
the hernial protrusion would be most tender, and pain might be 
absent at the ring. This symptom was, therefore, not reliable 
in all instances, nor would such differences be found in cases 
of longer standing. The condition of the integument afforded 
a better clue to differential diagnosis. Provided rude taxis 
had not been resorted to, the skin over a strangulated hernia 
would be found unaltered and freely movable. In inflammatory 
action about an empty sac, the subcutaneous tissue would be- 
come infiltrated, the skin itself would grow red, and after one or 
two days would adhere to the subjacent tissues. 

Vomiting was not a characteristic symptom. It might get 
progressively worse in inflammation of an empty sac. Consti- 
pation was equally unreliable, although there was no mechanical 
obstruction ; cases had been observed in which enemata and 
purgatives had produced no action of the bowels, not even the 
escape of flatus. The condition of the hernial tumor was not 
a trustworthy guide to go by. In inflammation of the empty 
sac, it might be impossible to effect a reduction in the size of 
the protrusion, just as in true strangulation. As regards the 
temperature of the body, it might materially aid differential 
diagnosis. In strangulated hernia, a febrile movement might 
be postponed to the third or even fifth day, whereas in in- 



350 HERNIA. 

fl animation of an empty sac, an early rise of temperature took 
place. 

In most cases of the latter description, the patients belonged 
to the female sex. This was owing to the fact that in women 
crural hernia was more frequent, this variety being, also, the one 
which oftener led to inflammation of the empty sac. No single 
symptom, therefore, could be safely relied upon, and even the 
conjoiued presence of several might still lead to a wrong diag- 
nosis. Surgeons were incidentally cautioned against pumping 
air into the bowels in giving injections, because the re-escape of 
such air might mislead one to assume the presence of flatus. 

13 Page 75. 

The principal thickness of the covering of a hernial sac is the 
superficial fascia, especially if the patient has a tendency to 
obesity. Its loose connections, yielding nature, and varying 
amount and want of permanence of fat, which is its chief bulky 
constituent, offers little obstruction against the descent of the 
hernia ; and in the operation of injection is little used as an 
effective agent of security. That it performs a secondary part 
in the operation may, however, be seen on pages 147 and 170. 

Its looseness is so great in some patients that an inexperienced 
hand may invaginate the scrotum under the skin of the groin so 
as to produce the appearance of having entered the external ring 
without getting into the inguinal ring at all. It is recorded 
that operations have even been done under these circumstances 
with results easily to be imagined. As a general rule the struc- 
tures involved in the anatomy of inguinal hernia are more de- 
cidedly evident to the touch, and their connection with each 
other less firm, when the hernia has been present in the canal 
for any length of time. This is remarkably the case in old 
scrotal hernias. 



OBSERVATIONS AND OPERATIONS. 351 

13 Page 86. 

The different points at which the layers of the abdominal 
walls react upon a distended hernial canal and produce stran- 
gulation o;jve us some hints of the assistance which nature will 
render in effecting a closure of the canal. The most frequent 
situation of strangulation is at the internal opening of the sac 
into the peritoneal cavity. Except in a certain class of cases, 
the increased danger of entering the abdominal cavity with in- 
struments would deter the surgeon from too freely including 
this part of the hernia in his manipulations. 

The next situation in the order of frequency of occurrence 
is at the lower border of the internal oblique and edge of the 
conjoined tendon. These structures can be easily reached. 
Occasionally, but least commonly and generally in large hernise, 
strangulation occurs at the external ring. This part may be 
reached and operated upon with the greatest ease and is effect- 
ually closed by adhesive action. If, however, nothing more is 
effected than the contraction of this distended ring, its closure 
does not prevent the formation of a bubonocele in the un- 
closed canal above, but may even allow a strangulation to occur 
at the internal ring. 

14 Page 88. 

In recent hernias which have become strangulated in young 
and healthy persons, inflammation soon begins in the protruded 
intestine and that part of it which lies above the stricture. If 
relief is not obtained, the intestine below mortifies or ulcerates. 
In recent strangulated hernias, there is pain in two distinct 
places ; at the umbilicus and extending from it to the pit of the 
stomach, and also in the hernial tumor. Both may be equally 
acute to the touch as well as to the sense of the patient. In old 
herniae that become strangulated, the pain is felt at first, and 



352 HERNIA. 

often for a long time, at the umbilicus alone. It is a peculiarity 
in inflammation of the intestines that the pain is referred to the 
umbilicus, whatever part of the intestines may be inflamed, be it 
jejunum or even rectum. Acute pain in this region, and also 
in the tumor in recent hernise, serves to mark a high degree of 
inflammation. 

Page 90. 

Dr. Lange, of New York, reported on March 8th, 1881,. a case 
of " reposition en bloc " made by the patient himself in the for- 
cible attempt to reduce an incarcerated inguinal hernia. The 
inguinal canal was wide and completely empty. One could feel 
at the end of it a stretched band, representing as shown during 
the operation, the spermatic cord pulled upward and outward by 
the sac which was lying in the retroperitoneal tissue a short dis- 
tance above Poupart's ligament, and was slightly marked by an 
insignificant elevation of the abdominal wall above it. A longi- 
tudinal incision was made above Poupart's ligament, and it was 
found that the sac was pushed upward, making an acute angle 
at its attachment to the internal ring, the latter being displaced 
backward toward the peritoneal cavity and allowing in this way 
the sac to slip in an upward direction behind the peritoneum. 
The sac was closed by suture and removed. The patient had a 
good and speedy recovery. 

Page 91. 

Dr. Erskine Mason narrates the following case of interstitial 
hernia with a lacerated neck of the sac. 

A man, aged fifty-five years, and single, gave a history of 
having first suffered from hernia in 1863, while in the army, 
and after lifting heavy weights. He had kept the hernia up 
part of the time with a pad and bandage, and lately had worn a 
truss, which was inefficient. On Saturday morning he was 



OBSERVATIONS AND OPERATIONS. 353 

taken with diarrhoea, and after he had had three or four move- 
ments, his hernia came down and he was unable to reduce it. 
He suffered great pain in the region of the hernia, went to the 
station-house, and from there was sent to Bellevue Hospital in an 
ambulance, where he arrived at about three o'clock in the after- 
noon. The house surgeon said that he was not at that time 
suffering from the symptoms of a strangulated hernia. On ex- 
amination, however, an incomplete hernia was found in the 
right iliac region about the size of an orange, which he tried to 
reduce by taxis, but failed. The patient was then placed in a 
hot bath, where he remained thirty minutes, after which a hypo- 
dermic injection of morphia was given, when the house surgeon 
again tried taxis, as also did other members of the staff, and the 
manipulation was kept up for about fifteen minutes. The mass 
then began to recede at once from the inguinal canal, and at the 
same time the house surgeon noticed the development of a tumor 
of about the size of that to which taxis had just been applied, 
and dull upon percussion above and outside the internal ring. 
A bandage was applied, and a stimulating enema was given, 
which produced no movement from the bowels. On the follow- 
ing morning, the man complained considerably of pain, and it 
was found that the hernia had again descended. Taxis was 
applied, and the tumor ascended as it had previously done, but 
vomiting supervened, pain returned and radiated over the abdo- 
men. At five o'clock in the afternoon Dr. Mason saw the 
patient, and found him much prostrated and suffering from 
severe pain in the abdomen, which was somewhat tympanitic. 
He found a swelling in the region above the internal ring, with 
slight fulness in the inguinal canal. By forcing the finger into 
the canal, and at the same time pressing upon the tumor from 
above, he could just reach the coil of intestine. 

The patient was put under the influence of ether, and Dr. 
Mason proceeded to operate. The sac contained a good deal of 



354 HERNIA. 

fluid, but it did not have a bad odor. At the neck of the sac 
a small knuckle of intestine was found, which was quite con- 
gested. He divided the neck of the sac and then proceeded to 
press against the intestine, when he found that it did not recede 
into the abdominal cavity. He drew the intestine down, but 
could not push back the part which protruded. The finger was 
then swept around the intestine, and in the posterior part of the 
neck of the sac a rent was found, which had permitted the coil 
of intestine to escape into the subperitoneal tissue, from whence 
it was gently drawn and readily passed into the abdominal cav- 
ity. The edges of the sac were united with catgut sutures. No 
unpleasant symptoms had followed the operation. The incision 
was made directly upon the cord, and the inguinal canal was 
opened. A drainage-tube was placed to the outside, and about 
the neck of the sac. The method of closing the sac with catgut 
sutures was one adopted by Mr. Southam, who had reported in 
the last number of the Lancet six cases in which it had been 
practised successfully. 

Page 92. 

The following case of intermuscular or intraparietal hernia 
reported by Dr. George F. Shrady, of New York, is interesting 
not only on account of its rarity, but also from a clinical point 
of view. 

The patient was a Scotchman, fifty-four years of age, whose 
left testicle had not descended until he was twenty-two years of 
age. When four years old he fell over an embankment, since 
which time he dated the occurrence of a hernia in the left o-roin. 
After the descent of the testicle the hernia appeared in the scro- 
tum also. Daring the greater part of his life he had worn a 
truss and suffered no more than the ordinary inconveniences at- 
tending a reducible inguino-scrotal hernia. About one year ago 
he had difficulty in returning the hernial contents, and suffered 



OBSERVATIONS AND OPERATIONS. 3.35 

from temporary strangulation. On the 4th of last December, 
while waiting upon a customer, the hernia came down, and the 
patient was unable to reduce it as formerly. Symptoms of 
strangulation soon after appeared, and Dr. F. W. O'Brien, of 
Harlem, was summoned. Failing in accomplishing the desired 
result by taxis, Dr. O'Brien advised an immediate operation. 
The patient would not consent to this measure, and determined 
to trust to the chances of his own efforts. 

Four days afterward Dr. M. J. Eoberts was called in to see 
the case, and also proposed an operation. The patient consented 
to have taxis tried under ether, but exacted a promise from Dr. 
Eoberts that no cutting operation should be performed. The 
patient awoke from the anaesthetic with the strangulation under- 
reduced. The following day I was called upon to perform her- 
niotomy. The patient was at that time in the fifth clay of 
strangulation, had an anxious expression, feeble, thready pulse, 
cool surface, and was constantly vomiting stercoraceous material. 
The hernia was situated on the left side, and presented some 
striking clinical features. The swelling, which was equal in 
size to a largely distended colon, extended continuously from 
above the anterior superior spine of the ilium to the fundus of 
the scrotum. The overlying tissues were tense, particularly 
those of the scrotum, and there was considerable tenderness 
over the external abdominal ring. The unusual situation and 
the peculiar shape of the tumor suggested at first the possibility 
of reduction en masse. The existence of such a condition was, 



however, disproven by careful examination, and by the assertion 
of the patient that the swelling had been there as long as he 
could remember, and that it was almost invariably larger after a 
hernia in the scrotum had been reduced. 

Percussion gave superficial intestinal resonance throughout 
the entire extent of the tumor. Inasmuch as the swelling ex- 
tended above the line of the internal ring, contained intestine, 



356 HERNIA. 

and was apparently situated in the substance of the abdominal 
walls, the diagnosis of intraparietal hernia was made. The ex- 
istence of the supplementary sac was believed to be due either 
to a previous rupture laterally of some portion of the vaginal 
process of the peritoneum, and the subsequent formation of a 
cyst around the escaped intestine, or to a true diverticulum of 
the peritoneum. It was proposed to cut down in the usual situ- 
ation, over the external ring, divide the stricture wherever it 
might be, and, if possible, reduce the contents of both sacs. But 
the patient again refused the operation. This was on Thursday. 
On the following Sunday, by request of one of the patient's 
family, Dr. O'Brien called Dr. Eipley in consultation. That 
gentleman, recognizing the urgency of the symptoms, advised 
immediate operation, but to no effect. To my surprise I learned 
that the patient was still alive on the eleventh day after the 
commencement of symptoms of strangulation, and that he had 
finally consented to an operation. He had been in the mean 
while very much reduced by constant vomiting. When I saw 
him at that time, in company with Drs. O'Brien, Boberts, and 
John Shrady, he was evidently fast sinking, and it was decided 
not to take the chances of the patient dying during an operation. 
The site of the hernia was infiltrated, ecchymosed, and oedema- 
tous. This condition was assumed to be due to slouching of the 
strangulated gut, and the discharge of its contents into the sur- 
rounding areolar tissue. The patient died shortly after my visit. 
The autopsy was made the day following, by Dr. W. H. Por- 
ter, who verified the diagnosis which had been made before 
death. The tissues of both the groin and scrotum were im- 
mensely thickened by fecal infiltration and resulting inflamma- 
tory processes. At the seat of constriction, which was the 
external ring, the walls of the gut had sloughed entirely through 
on one side and partially through on the other, allowing the 
escape of fecal fluids into the adjacent tissues. The hernia was 



OBSERVATIONS AND OPERATIONS. 357 

of the congenital variety, the sac being formed by the vaginal 
process of the peritoneum. Continuous with this sac, was a 
diverticulum of peritoneum, seven inches long, extending from 
the inguinal canal upwards above the anterior superior spine of 
ilium and between the external and internal oblique muscles. 
The diverticular sac contained several knuckles of ilium, which 
had found their way thither through the enormously enlarged 
internal rin^. 

As previously stated, this form of hernia is rare. So far as 
can be learned from the meagre literature upon the subject (as 
contributed by Birkett, Bryant, Klebs, Hartung, and Lenhart), 
interparietal hernia is associated with the congenital variety, 
and is probably due to the existence of a congenital diverticu- 
lum of peritoneum in the inguinal canal. In this particular in- 
stance, the left testicle remaining in the inguinal canal until the 
twenty-second year may have been an important factor, if not 
in the actual production of the diverticulum, at least in its early 
development. It is quite probable that the hernia produced at 
four vears of ao;e was in the diverticulum, the undescended tes- 
tide virtually plugging up the inguinal canal. Up to the time 
of the descent of the testicle, the intraparietal sac was being 
constantly stretched, as was also the internal ring. When the 
testicle descended, the vaginal process of the peritoneum re- 
mained open, and of course formed the sac for the congenital 
hernia. 

The clinical features in this case are of great importance. 
The principal interest centres in the possibility of making a cor- 
rect diagnosis. In the present instance this was not difficult, 
owing to the history of the case and the general appearance of 
the swelling. The tumor was of long standing, it extended ex- 
ternal to and above the internal ring, it contained intestine, and 
was quite superficial. The treatment in case of strangulation 
would, as in the present instance, involve the consideration of 



358 HERNIA. 

possible stricture either at the external or internal ring, or within 
the diverticulum itself. If by any chance a diagnosis of the 
condition of the parts is not made in such cases, it is easy to 
understand how a herniotomy for strangulation might result in 
confusion to the operator, and in his possible failure to save the 
patient's life. 

15 Page 94. 

" But why operate at all ? This will at once be propounded 
by many conservative practitioners, especially in the light of 
present medical teaching. There are many and sufficient reasons 
in my opinion. 

"A patient with an infirmity of this character is imperfect, 
and the consciousness of it, if not always depressing, is at least 
very annoying. The wearing of a truss is an inconvenience 
of which many would gladly rid themselves. Some persons, 
again, cannot satisfactorily be fitted with a truss. I know of a 
case in the practice of a prominent physician here, in Buffalo, 
where, owing to the presence of a fatty tumor, the proper ad- 
justment of a truss is almost out of the question. A hernia 
unreduced or irreducible, is liable to many grave accidents, too 
well known to require mention. A man with this defect, no 
matter how slight, or what his physical condition otherwise, his 
social or intellectual standing, is debarred from entering the ser- 
vices of the United States, the Army, Navy, Marine Hospital 
Service, Revenue Marine, etc., which to many is a field where 
their tastes would lead ; and if the physical examination of sea- 
men for the Merchant Marine becomes compulsory, it will pre- 
vent many men from shipping and earning their living in that 
manner. Considering the large number who are defective in 
this respect, it becomes a serious question, and any reasonable 
method which can remove it, is to be carefully entertained. In 
the United States, there are about one in every fifteen, who 



OBSERVATIONS AND OPERATIONS. 350 

carry a hernia (Agnew) ; in France, one in thirteen (Malgaine). 
Out of 334,321 men examined during the war, 17,296 were 
rejected (Agnew), and of all the varieties of hernia, the inguinal 
was the most frequent." — W. H. Heath, M.D., Assistant Surgeon 
TJ. S. Marine Hospital Service. 

16 Page 98. 
historical sketch. 

The first mention we find of an attempt at a cure of hernia is 
in Celsus (lib. 7, cap. 20) ; he speaks of the treatment of ingui- 
nal hernia as an operation generally known to the surgeons of 
the Alexandrian school, although he quotes no authorities upon 
the subject. He did not operate upon hernias that were very 
voluminous and recommends before operating on young chil- 
dren, to try the effect of pressure, by means of a bandage and 
compress placed over the seat of rupture ; a method which he 
says is frequently successful. His method of operating was 
either by ligature, or by suture, or by excision of the sac for 
which he gives two processes, according to the age of the pa- 
tient. He did not extirpate the testicle in this operation, unless 
it was diseased or had adhered to the sac so that it could not be 
separated from it. 

In the hundred and fifty years that followed Celsus to the 
time of Galen, we find nothing more upon the subject. Galen 
himself in his book, Be Tumoribus prceter Naturam (lib. VI.), 
adds nothing to what was already known ; he simply repeats 
the doctrines of Celsus. Leonidas of Alexandria lived about 
this time ; he distinguished hernia with rupture of the perito- 
neum from hernia without rupture (congenital hernia), and con- 
siders the latter the more difficult to cure. In the two centuries 
that follow Galen, to the time of Oribases, we again find noth- 
ing more upon the subject. iEtius, in the fifth century (lib. IV. 



360 HERNIA. 

ser. 2, cap. 24), makes the first mention of cauterization, and 
prefers it to any other treatment, although allowing that a cure 
may be effected by astringents. We then find nothing more 
until we come in the seventh century to Paulus, who was the 
last Greek surgeon of any note. He gives with more detail the 
operations previously described by Celsus ; in the operation by 
excision he recommended a ligature to be applied to the sac 
before the operation. 

After Paulus, the northern barbarians devastated Europe, and 
overwhelmed science and the arts in the darkness of their de- 
struction. The Arabians, however, still kept the light of knowl- 
edge burning ; but because of their prejudice against bloody 
operations, they confined themselves in the treatment of hernia 
almost entirely to the use of plasters, using occasionally, how- 
ever, the actual cautery. John, son of Serapion, was the first 
to teach that inguinal hernia was caused by the dilatation of 
the canal through which pass the spermatic vessels. He recom- 
mended cauterizing the part in order to reduce the size of the 
opening by the contraction caused by the cicatrix. Albucasis, 
in the first part of the twelfth century, warmly recommended 
the actual cautery (lib. II. fol. 67). He cauterized the inguinal 
region in the direction of the canal, but forbade opening the sac. 
In the interval from the twelfth century to the fourteenth, sur- 
gery did little but follow in the steps of the Arabs. It was in 
this period that the empirical treatment of hernia reached its 
height, and it was also from this time that castration became so 
common as to excite the hatred of the Pope. 

Lanfranc in 1296 (lib. 3, cap. 3, sec. 3) disapproves of cauteri- 
zation and incision and recommends topical applications. He 
describes, however, a method of cauterizing to the bone, after 
having first raised up the spermatic cord. Guy de Chauliac in 
1363 (Tractat. 6, cap. 7) describes the operations in use at his 
time. He mentions the section of the spermatic cord, castration, 



OBSERVATIONS AND OPERATIONS. 361 

cauterization, both actual and potential, and ligature of the cord 
, by means of a thread passed under it, then tied over a small 
piece of wood and tightened every day until the parts were 
divided. He preferred the potential cautery by means of arse- 
nic, and states that he had seen his master, Petrus de Bonanti, 
perform the operation successfully more than thirty times. 
From the sixteenth century to the nineteenth, the cure of her- 
nia consisted almost entirely in compression and rest, and it 
was during this period that Blegny {II Art de Guerir des Hernies, 
Paris, 1676) invented the elastic truss. — From Henry Bryant's 
Essay. 

The intelligent reader will at once perceive that these older 
operations were by no means calculated to accomplish the cure 
which they pretended, for the attention of the surgeon in olden 
times was directed solely to the external ring, the anatomy of 

the internal one not being understood at that time. Therefore, 

■* 
supposing that the descent of the viscera into the scrotum were 

prevented, no provision was made against its further appearance 
in the groin. To account for the frequent recourse to these pain- 
ful/ and dangerous operations, we must suppose that the trusses 
then in use were totally inadequate to sustain the hernia within 
the abdomen. This supposition is strengthened by the declara- 
tion of Arnaud, " that when he was appointed truss-maker to the 
Military Hospitals of Paris, the storehouses belonging to those 
hospitals were filled with trusses which it was impossible to use, 
because they were of only three different sizes, and contrived 
for only one kind of rupture." We may also form some idea of 
their inefficacy by the description he gives of his own instru- 
ments, the construction of which he tells us was remarkably 
perfect, although in fact they were of the most imperfect de- 
sign. 



362 HERNIA. 

17 Page 98. 

The following medication, taken from Julius Caesar Claudius, 
will give a better idea of the extent to which quackery was 
carried : — 

H; Terra sigil. 
Mumniie. 
Sang. drac. 

Sang, humani, aTaT 3yi 

Bol. arm. 
Litharge. 
Oppoponcis. 

Galba, a. a. 3nss 

Nucum cupressi. 

Nuci musci, a. a. 3 j 

Moschi, . 3ss 

Eos. rub 3 n 

Thuri, 3«5 

Cort. thuri, 5iij 

Sarcollse, 3 nss 

Acacia?. 
Balnas. 
Costic, gran, consol, maie et min. 

Sang, hirci, a. a. 3j 

Pil. lopori usti. 
Pellis ejusdem. 

Pilae erici, a. a. 3 j 

Gall tapsi barbati, 3 iss 

Picis Hispan. 

Gummis elemi, a. a. 3 j 

Mastiches, §iss 

Consol medise, 31j 

Gum Arab § j 

Tragac iiss 

Gypsi. 

Sang, vespertillii, a. a. 3tf 

Myrti, 3nj 

Pici graecui, 3 ss 

M. et pul. pulveris ac gum in acete, dissolv, cum ol. abiet. Ft. 
ceratum. 



OBSERVATIONS AND OPERATIONS. 363 

Fabricius ab Aquapendente said : " The operation for hernia 
is so dreadful and dangerous that, although many escape, many 
nevertheless die under it, or soon after ; whence it happens that 
surgeons undertake to cure these patients as desperate cases. 
On which account I have always been of opinion that patients 
ought on no account to expose themselves to this danger, espe- 
cially being able to wear the truss during the whole of their life 
without the risk of shortening it a single day, which advice I 
gave the more willingly as conversing lately with Horatio Norsia, 
an operator very skilful in this matter ; he told me that formerly 
he had every year operated on more than two hundred patients, 
and that at present he scarcely operated on twenty; and he 
replied to me on my asking the reason, because many cured 
themselves by wearing a truss and applying stringent applica- 
tions." 

18 Page 99. 

Albucasis, Avicennes, Eoger, Brunnes, Theodoric, and Guy de 
Chauliac preferred the actual cautery, while Jean de Crepatis, 
Andre de Montpellier, and Pierre d'Orliat, the potential. After 
the eschar was formed, the surgeon scarified it to the bone, and 
then made another application in order to penetrate to the bone. 
After the second eschar had formed, the wound was made to 
cicatrize. 

One method of cauterization, viz., by causing ulceration of the 
coverings of the hernia by the use of sulphuric acid, was so 
famous in England, in the latter part of the eighteenth century, 
as to induce George I. to bestow knighthood upon Little John, 
an impudent quack, and to give him £500 yearly as a reward, 
and in addition £5,000 for his secret nostrum. It was this 
operation which caused the death of the celebrated Condamine. 
In 1773, the Academie Royale de Chirurgie unanimously con- 
demned the pretended method of cure. 



364 HERNIA. 

19 Page 99. 

It was performed even as lately as 1832, when M. Larrey 
read before the Academie des Sciences an unfavorable report 
npon an operation proposed by M. Bertrancl, of incising the sac, 
and then filling its cavity with lint to excite inflammation. 

80 Page 102. 

In 1710, Hooper was sent to the galleys for operating by castra- 
tion ; and a woman in Rheims was publicly whipped in 1735 for 
the same offence. Most surgeons will, however, be surprised to 
learn that it was practised in France even as late as the begin- 
ning of the nineteenth century. Such, at least, was the case in 
1796, when Sabatier published his Operative Surgery, although 
a law had been passed as early as 1730 making it felony to 
practise it. In the report made to the Royal Society of Medi- 
cine, in 1779, by Poultier de la Salle and Vicq d'Azyr, the 
Chief of Parisian Police states that a large number of the re- 
cruits inspected by him before entering the army had lost one 
or both of their testicles by this operation ; and the Bishop of 
St. Papoul found in his diocese that five hundred had been simi- 
larly mutilated. 

31 Page 103. 

Grcefes Operation (described by Dr. Raw, Berlin. Thesis 
1813). An incision being made through the integuments, the 
sac is dissected from the cellular tissue, raised with a pair of 
forceps, and cut off. Then a plug of lint rubbed with some 
ointment is introduced into the neck of the sac, so as not only 
to touch all parts of the internal ring, but even to project into 
the abdominal cavity. A string is attached to the plug to with- 
draw it when necessary. The next morning the plug is exam • 
ined. If it offers any resistance, it shows that inflammation 



OBSERVATIONS AND OPERATIONS. 3G5 

has been set up, and should not be interfered with. In this 
case the plug will detach itself in three or four days, and is 
then withdrawn. A second plug, anointed perhaps with red 
precipitate ointment, is then introduced to cause suppuration of 
the whole internal surface of the sac. In a few clays laudable 
pus and granulations are forming. The complete cicatrization 
is said to be often obtained in a month. That so barbarous and 
unscientific a process should be recommended by so noted a 
surgeon, and at so late a date, seems almost incredible. How 
the operation can fail to produce fatal peritonitis it is difficult 
to imaoine. 

o 

23 Page 105. 

Dr. Eanz [Gaz. Tosc. delict Sci. Med., May, 1845) attributes 
the want of success to three causes : " 1st. That, in invaginating 
the skin of the scrotum in the inguinal canal, the sac of the 
hernia separates itself from the integuments, which then pass 
between it and the walls of the canal. 2d. That the invagina- 
tion does not stop up the whole canal, being fixed by the liga- 
ture only to the anterior wall ; the whole posterior half remains 
open. 3d. That the invaginated portion of the integument re- 
turns to its place, and the effused lymph is soon absorbed." 

83 Page 106. 

Bonnet, in his memoir read before the Academy, comes to the 
following conclusions : " 1st. The operation ought not to be at- 
tempted on old people. 2d. That it does not afford any chance 
of durable success in adults when the hernia is very voluminous. 
3d. That in adults, when the hernia is small and the canal still 
oblique and of small diameter, the operation can be performed 
with great success ; and that it is equally successful in children, 
whatever is the size of the hernia or the state of the canal." 

M. Mayor gives the following explanation of his method of 



366 HERNIA. 

cure : " 1st. The strong tension of the skin over the opening 
through which passes the hernia closes it, at least for a time, and 
opposes energetically a renewal of the hernia. 2d. The imme- 
diate swelling of the subcutaneous fatty tissue takes an active 
part in the process of cure ; it swells up, and as it cannot develop 
itself toward the skin, it is obliged to take the direction of the 
ring to fill the opening, and lastly to contract adherences with 
the adjacent parts. 3d. The inflammatory swelling which takes 
place in the part near the ring and in the ring itself causes ad- 
hesive inflammation of these parts. 4th. A secretion of plastic 
lymph which unites all the parts together. 5th. The thickening 
and solidification of the same lymph." 

24 Page 129. 
first operator on hernia by the method of injection. 

It is often extremely difficult to trace with precision the 
author or inventor of an operation where several make claim to be 
the first in the field. As I have already hinted in the Introduc- 
tion, the method of treating hernia by injection may be of Egyptian 
or Assyrian origin, and the discoveries of Schliemann and others 
may yet reveal more of the early efforts in the healing art than 
we can now understand, since " prehistoric man was doubtless 
a victim to injury before he became a sufferer from disease." 

It is however recorded that the operation was first tried by 
Desault upon a congenital hernia, but without any success, as 
after the inflammation had subsided the hernia returned. Velpeau 
conceived the operation in 1835, but did not operate until 1837 
(Medecine Operatoire, 2d ed., vol. iv.), and then not until he 
had first cut down upon the parts. 

On the other hand, from information which I have obtained 
from records and documents, and other sources I am convinced 
that the honor of the discovery of the subcutaneous operation 
and method of curing hernia by injection, belongs rightly to my 
esteemed and distinguished fellow-countryman, Professor Joseph 



OBSERVATIONS AND OPERATIONS. 367 

Pancoast, M.D., who operated on thirteen cases of hernia in 1836, 
using Lugol's solution of iodine, or tincture of cantharides. He 
was at that time Surgeon in the Philadelphia Hospital. Vide 
page 283 of the Treatise upon Operative Surgery, by Joseph 
Pancoast, M.D., 1844. The instrument there figured and de- 
scribed is similar to the one used by Dr. Heaton in his first 
operation, in 1840^1. Vide present work, page 370. Dr. 
Heaton experimented with Lugol's solution of iodine, tincture 
of cantharides, essential oils, and various other liquids ; but soon 
abandoned these for the extract of Quercus alba. 

In the present work I have given to Dr. Heaton the honor 
and credit of being the originator of the method of injection for 
the cure of hernia ; but I am convinced that the first operator 
who used this method was Professor Joseph Pancoast, and to 
him belongs the honor of originating it. Dr. Heaton, by experi- 
mentation, found a fluid more suitable for the purpose than that 
used by Professor Pancoast. 

In honor of Professor Pancoast, who originated the method of 
injection, I would therefore most respectfully suggest the pro- 
priety of calling the operation the " Pancoast Operation for the 
Cure of Hernia by the Subcutaneous Method." 

It is a noticeable and interesting fact, however, that both 
Yelpeau and Pancoast punctured and made their injection into 
the hernial sac. The student and practitioner is earnestly re- 
ferred by the author to pages 149 and 206. It will be seen 
that the author injects not the sac, but throws his injection into 
the rings and around the sac. This is a very important fact, 
both from an historical point of view and in the successful treat- 
ment and cure of hernia. 

515 Page 140, 

I am happy to be sustained in my views upon this method of 
treating inflammations and abdominal wounds by so good an 



368 HERNIA. 

authority as Surgeon Doherty, of the United States Army. In 
Circular No. 3 of the Army Reports, he has said that ice bags or 
bladders are often too intense in their effects, are painful upon 
prolonged contact with the part, and involve too much incon- 
venience for permanent and satisfactory use. Ice poultices, prop- 
erly made, combine all of their advantages with none of their 
disadvantages, being safe and convenient, and producing a per- 
manent, uniform reduction of the temperature. They cause no 
pain, no chilliness, no inconvenience from their weight, and 
admit of easy application. They do not require removal oftener 
than once in two or three hours, do not saturate the clothes of 
the patient, and require no special arrangement for their use. 

Maisonneuve's directions for the application of cold are sub- 
stantially as follows : Take of linseed meal a sufficient quantity 
to form a layer from three quarters to an inch thick ; spread it 
upon a cloth of proper size ; upon this, at intervals of an inch 
or more, place lumps of ice of convenient size — of a big marble, 
-^ then sprinkle them over lightly with the meal ; cover with 
another cloth, folding in the edges to prevent the escape of the 
mass ; and apply the thick side to the surface or wound. The 
ice is closely enveloped by the meal, the exclusion of the air 
retards the melting of the ice, and the thick layer, intervening 
between it and the surface of the body, prevents painful or in- 
jurious contact. Linseed meal is better for this use than bran 
or similar materials, because its mucilaginous properties render 
it somewhat tenacious and adhesive. 

26 Page 140. 

fibroplastic lymph. 

" J. Hunter and his followers, the French surgeons, up to the 
present time, have maintained that this plastic lymph is derived 
from the vessels by exudation, is susceptible of organization, and 
of the formation of the different tissues met with in cicatrices. 



OBSERVATIONS AND OPERATIONS. 369 

In this grayish opalescent layer composed of lymph filaments 
of fibrin, there are found white corpuscles or pus cells, and red 
blood corpuscles. Beneath this superficial layer, the fasciculi of 
the connective tissue and the blood capillaries are separated from 
each other by the same opalescent substance, so as to constitute 
a kind of membrane, continuous and extremely thin. From 
this description, it is seen that at the moment when this so-called 
lymph becomes solid, it contains cellular elements. At the 
present time these facts might be explained by the white blood 
corpuscles passing out of the vessels and the coagulation of the 
fibrinogenic substance (Cohnheim). Yet this explanation is not 
sufficient, for it is very possible that the lymph contained in the 
lymphatic vessels, and in the meshes of the connective tissue, 
plays some part in these phenomena. It has been mentioned 
that the white or lymph corpuscles are found free between the 
fasciculi of the connective tissue. Again, the conditions for the 
formation of fibrin are far from being perfectly understood. It 
is only known that the plasma of the blood, abstracted from the 
vessels, coming in contact with the paraglobulin (Kuhne), and 
other substances contained in* the histological elements, takes 
the form of fibrin. What is difficult to understand is, why the 
blood plasma, lymph, and serum of the pericardium, which con- 
tain the fibrinogenic substance, never give origin to fibrin in 
the living organism, although these fluids are in contact with 
elements containing the fibrinoplastic substance. 

" The infiltration of connective tissue by a notable quantity of 
round elements can generally be recognized only with the mi- 
croscope. In this peripheral zone there are very manifestly 
seen a swelling of the flat cells of the connective tissue, a divi- 
sion of their nuclei, and a consequent proliferation of these 
cells. 

" From this description it is seen that the abundant production 
of new cellular elements, between the constituent parts of the 



370 



HEKNIA. 



connective tissue, may come from two sources; the passing out 

of the white blood corpuscles, and the multiplication of the cells 

of the connective tissue. 

" Cornil and Ranvier." 

Page 143. 



\ 



e 



i 




Fig. 80. — Heaton's Case of Instruments. 

(a) — Instrument for injecting the solid extract of Oak Bark, which he seldom used. 

(b) — Syringe for injecting the fluid extract of White Oak Bark, by which he effected the most 

of his cures. 
(c, d, e) — Instruments used in the operation of variocele. 
(,/) — An instrument which acted as a scarificator, and at the same time was used to introduce 

the solid extract. 



OBSERVATIONS AND OPERATIONS. 371 

w Page 148. 

heaton's formula. 

ft Fl. Ext. Querci Albae S j 

Solid Ext. Querci Albse gr. xtv 

Morphl. sulph . . . gr. ij 

M. Sig. Inject 8 to 10 drops. 



The following formulae I have devised, and find to be the 
very best for injection : — 

FORMULA A. 

For infants and children, whether the hernia be accidental or 
congenital : — 

ft Fl. Ext. Querci Albse g ij 

Reduced by distillation to § j 

Alcohol 70% Sir 

Ether, sulph . 3| 

Morph. sulph '. gr. ss 

M. Sig. Inject 8 to 10 drops. 

FORMULA B. 

For old and long-standing hernse in adults, whether congenital 
or acquired, I used the following in my first operations : — 

ft Fl. Ext. Querci Albse § fv 

Reduced by distillation to §j 

Alcohol 90% .-. 5 in 

Ether, sulph 5 fj 

Morph. sulph gr. fj 

M. Sig. Inject 10 to 25 drops. 

FORMULA C. 

The very best formula, however, which I have ever used is 
the following. It is the one I now recommend for most cases 
in the adult person. 



372 HERNIA. 

R Fl. Ext. Querci Albae § yj 

Reduced by distillation to § fj 

Alcohol 90% • • Sb5 

Ether, sulph. . . . . 3n 

Morph. sulph gr. iv 

Tr. Veratri Viridis 3 fj 

M. Sig. Inject 15 to 20 drops in small and recent 
heriiise, but 25 to 50 drops in large or old hernise. 

Of this irritating mixture, we can rise a much larger amount 
than of any other I have ever used, and with more impunity. 
I have often, during the past year, injected large doses without 
forming any local suppurations or abscesses. In one case I had 
a very slight superficial irritation of the size of a pea, such as we 
often see after the hypodermic injection of fluid extract of ergot. 
The greatest advantage, however, in the formula is that we get a 
very marked reduction of pulse and temperature, which often 
comes on so suddenly that we have to apply a bottle of hot 
water to the patient's feet. This reduction may last as long as 
forty-eight hours, thus giving us a decided advantage during the 
very period in which we most desire to keep down the tempera- 
ture, and allowing us to gain a more decided local effect of our 
irritant. It will be readily seen also that nearly all, if not quite 
all, of the ingredients used are antiseptic in their action ; so that 
we may claim, in addition to the simplicity and all the other 
advantages of the subcutaneous method of treating hernia, the 
peculiar advantages of the antiseptic methods that have been 
mentioned. 

28 Pages 149 and 205. 

operation by injection. 

The operation by injection, as described in many text-books 
of surgery — even the most recent, — has been thus strangely 
misunderstood. See also page 367. By injecting the hernial 
rings, the effect is very different from what it would be if the 



OBSERVATIONS AND OPERATIONS. 



373 



irritant were introduced into the neck of the sac. In the latter, 
it would simply act upon opposing serous surfaces and produce 
an effusion of serum or sero-purulent matter. A portion of 
such effusion, it is true, might consist of lymph, and cause the 
opposing surfaces of the sac to unite by adhesions with more or 
less apparent organization. The persistency of such a result, 
however, would be very uncertain, and it could scarcely termi- 
nate in a trustworthy cure of the hernia. For if these adhesions 
should not soon diminish or disappear by absorption, the protru- 
sion, if it could not re-enter the old sac, would 
sooner or later force down a new one through 
the still undiminished or even gaping fibrous 
opening. This was long ago pointed out also 
by Lawrence in his able treatise On Ruptures. 
On the other hand, the lymph produced by the 
injection into the rings " has a natural tendency 
to organize into tissue similar to that which 
gave it birth, thus thickening by interstitial 
formation the whole series of fasciae, contracting 
the rings both directly and indirectly." See 
also pages 129 and 381. 

29 Page 157. 

my new instrument. 

Being desirous of having a lighter and less 
complicated instrument for performing the oper- 
ation of subcutaneous injection, I have devised 
the instrument here figured. This was made 
for me by Messrs. Cod man & Shurtleff, of Bos- 
ton, and by Milliken & Down, of London. It is 
equally as effective as the one figured and de- 
scribed on page 157, and is not a quarter part 

Fig. 81- 



374 HERNIA. 

as expensive. In general appearance it is similar to my first 
syringe (figured on page 144). It has a valve by which we can 
control the fluid; the head of the needle revolves on a ruby, and 
a spiral spring upon the piston within the barrel forces the 
plunger down upon the fluid, ejecting it through the valve. A 
screw on the piston, similar to that seen on the common hypo- 
dermic syringe, regulates, with great certainty, the number of 
drops of fluid we wish to use. 

This is my latest device, and it is very much lighter, and more 
fully under control of the operator, than any of my previous 
instruments. 

so Page 167. 

BANDAGES. 

To facilitate the operation still more, I would present to your 
attention the following remarks upon bandages, since bandages 
and compressing pads are a very important factor in obtaining 
our satisfactory results. It will be found that a strong elastic 
bandage, or, still better, one of pure rubber, will be of very great 
advantage in maintaining perfect compression of the parts dur- 
ing all of the treatment. Such a bandage does not slacken by 
stretching, as does ordinary cotton or linen cloth. It should not 
be drawn very tight for the first four or five days. After this 
time, if the swelling and inflammation be not too great, the 
bandage may be tightened so as to compress a little more severely, 
but not enough to give rise to much pain or discomfort. 

We should always remember that pressure is of the greatest 
importance in obtaining a successful issue in many operations, 
and particularly in this operation under consideration. Nothing 
can equal this rubber bandage for obtaining a firm, but gentle, 
pressure. 

This bandage, when pure rubber, should be 6 or 8 feet long, 
and 3 or 3J inches wide, and of the thickness usually in use. 



OBSERVATIONS AND OPERATIONS. 375 

It can have a tape attached to one end, sufficient in length to 
pass around the body and be tied above the symphysis pubis in 
a bow knot. Before applying the bandage I usually apply a thin 
piece of coarse cotton or linen cloth next the parts, to absorb 
perspiration and give a more agreeable sensation than the clammy 
rubber would give. In adjusting this rubber bandage we can, 
by passing the fingers beneath it, judge the amount of pressure 
proper to apply. This same equal pressure can be constantly 
maintained, as we pass the bandage around the body twice or 
thrice. 

The elastic webbing is too thick and bungling to be adjusted 
well, so that I have abandoned its use in these operations. I 
prefer that the perineal bandage should be made of cotton 
flannel, as it is much softer than linen. Those who prefer linen, 
however, will find that a little cotton rolled within it will make 
it far easier to the patient. 

The head of this bandage should be fastened over the tro- 
chanter and brought not too spirally around the hip, and fastened 
by passing it under the rubber bandage, and bringing the end 
over to make a loop, that can be pinned in front by the ordinary 
safety pins. It should not be drawn so tight as to narrow or 
contract the rubber bandage. A linen napkin, folded so as to be 
about three or four inches wide and forming a compress about 
one half an inch in thickness, will be found to make a satisfac- 
tory compress. 

31 Page 210. 

Another method has been devised and successfully applied to 
irreducible hernias by my distinguished friend J. Collins Warren, 
editor of the Boston Medical and Surgical Journal, Instructor 
of Surgery at the Harvard Medical School and Surgeon at the 
Massachusetts General Hospital. His plan is to use a "rubber 
water bag externally inelastic, but containing an elastic lining 



376 HERNIA. 

inclosing a space to which water or air could be admitted by 
a tube." To this a stout T bandage is sewed to secure it in the 
scrotum. When once buckled in place, the bag is pressed 
firmly down upon the pillars of the ring by thick wooden pads. 
Water may now be forced in at any desired pressure, and con- 
tinued for any length of time. It is indeed a great improvement 
over the simple rubber bandage devised by Maisonneuve. If 
uniformly successful, it will give us a fair prospect of relieving 
many cases hitherto incurable, except by the more serious opera- 
tions of herniotomy, because, manifestly, if hernias hitherto irre- 
ducible may be reduced, they will then be subject to the same 
conditions of treatment as the reducible. 

3 * Page 217. 

M. Seutin, the eminent surgeon of Brussels, made some ex- 
periments in 1856 to establish the superiority of tearing either 
the inguinal or crural ring, over the operation of incising the 
same for the reduction of strangulated hernia. He made experi- 
ments on the cadaver, and had several succesful cases in prac- 
tice. He places, first, great reliance on graduated taxis, continued 
with due precautions, for a considerable period ; when this fails, 
he endeavors to hook his index finger around the margin of the 
ring by passing it between the tumor and the abdomen ; by 
using a certain amount of force he then causes the fibres of the 
external oblique to give way and tear to an extent sufficient for 
the reduction of the hernia. The method is a o'ood one in 
many cases. 

The operation for strangulated hernia has been known only 
since the time of Eousset. Maupasius seems to have been the 
first to demonstrate its advantages. Aymar and Formi, however, 
had recourse to it with success in the sixteenth and seventeenth 
centuries. Up to that period kelotomy had not been performed 
except for the radical cure of hernia. 



OBSERVATIONS AND OPERATIONS. 



377 



33 Page 221. 




Fig. 82 — Author's Herniotomy Case. 1. Golding Bird's Torsion Forceps. 2. Scalpel. 
3. Author's Herniotomy Knife. 4. Author's Aspirating Needle. 5. Scissors. 



34 Page 221. 

Giinz, Camper, Louis, Hevermann, Callisen, Bell, and Wilnier 
paid little attention to the epigastric artery, and said that the 
fears of surgeons of wounding it in dividing the inguinal ring 
were vain and ill-founded. Upon this point Bertrandi says, 
" I can affirm that I have opened the bodies of men who have 
died a few hours after this operation (speaking of the incision of 
an incarcerated inguinal hernia), although performed with great 
facility, dexterity, and quickness, so that the operators thought 
highly of themselves on that account ; and they were quite 
astonished, and could not comprehend the cause of so unex- 
pected deaths ; but their astonishment ceased when they saw 
the abdomen full of blood discharged from this artery (epigastric) 
wounded." 

On the other hand, surgeons were not ignorant, even before 



378 HERNIA. 

the time of Arnaud, that the incision of Poupart's ligament, to 
free femoral hernia in the male from strangulation, was a very 
dangerous operation. They supposed, however, that the danger 
here was also in injuring the epigastric artery, but Arnaud was 
the first to point out the important "fact that in the male the 
spermatic cord passing over the neck of the hernial sac in a 
semicircular manner, and running immediately behind the mar- 
gin of the ligament, was much more exposed to the injury than 
the epigastric artery in either sex." 



CHAPTER XV. 

Besume' and Clinical Eeports. 

We said in the first edition of this work that we could not 
then in all truth and candor give so systematic and conclusive 
results of our operation as we could desire, but hoped to do so 
in some future edition. From the very many successful cures 
that have since occurred, both in the author's practice and in 
the practice of many most trustworthy and conservative gentle- 
men in the profession, we are confident and happy in saying that 
Ave can now give even more favorable reports than we then 
anticipated even with our most buoyant expectations. If any, 
however, should prefer some other operative measure rather than 
the painless subcutaneous injection, he will, I think, find it 
clearly described in the preceding pages. 

I am fully convinced that the grand and essential reason why 
the injection method succeeds so uniformly in attaining a per- 
manent cure of hernia, while all other methods have more or 
less failures, is that it gives us local inflammation about the 
rings and canal, but no tendency to suppuration. Suppuration, 
as I have already said, weakens the surrounding tissues and pre- 
vents their consolidation. This weakening influence is also seen 
in the tendency that abscesses in the groin have to produce 
a relaxation of the fibres about the rings, and consequently a 
hernia. The reader will remember that in my first two or three 
cases I did have slight suppurations, and said at the time that 



380 HERNIA. 

I feared the result of the operation would, on that account, not 
be a successful one ; but from the time that I have used my 
new combination of fluids, I have had not even incipient signs 
of suppuration, and therefore I have had uniform success. 

Just so far as an operation for hernia tends to produce sup- 
puration, just so far will it be ineffectual in attaining a cure. 
On the other hand, let inflammation without suppuration be set 
up, and we shall produce a contraction and consolidation of tissue. 
The principle of this theory may perhaps be illustrated by the 
consequences of a burn or scald upon the skin. Wherever the 
injury has been so severe as to produce suppuration, we do not 
get a contraction and distortion, but only a deep and smooth 
cicatrix. Where, on the other hand, we do not have abun- 
dant suppuration, but only a serous exudation, we get the con- 
tractions and distortions that require much surgical skill to 
remove successfully. The same principle, in another phase, is 
seen in tenotomy; when we have not thoroughly and completely 
divided the tendons and fasciae covering the muscles, we shall 
be sadly disappointed in the results of our operation, for instead 
of relieving the traction we have increased it, because we have 
irritated, and hence inflamed the fibrous structures. The oper- 
ation for strabismus often fails, too, for the very same reason, — 
failure to divide the fasciae of the muscles. 

It will thus be made evident that I maintain that the oper- 
ation for hernia by injection is successful not because it pro- 
duces tendinous irritation simply, but because it produces both 
tendinous irritation and local inflammation without suppuration. 
This is an important distinction, both as regards the theory and 
also as regards the practical success and permanence of the oper- 
ation. All other methods have accepted and expected suppura- 
tion as an accompaniment of the operative procedure, and have 
not been disappointed when they obtained it. This method avoids 
suppuration, as it would every other unfavorable complication. 



RESUME AND CLINICAL REPORTS. 381 

Other methods cannot avoid suppuration ; this method can and 
does avoid it, when properly performed, and with the proper 
fluids. The value of the various antiseptic methods and ligatures 
in treating hernial protrusions is, then, simply that they make 
an attempt, however successful, to avoid suppurative inflamma- 
tion. 

As regards the fluids that have been used for injection, it may 
be said that it is altogether probable that many have failed be- 
cause they were absorbed before they had produced the inflam- 
mation necessary to produce consolidation. Some have supposed 
that the chief value of Quercus Alba lay in its power of pro- 
ducing contraction of the tissues by virtue of its astringent 
properties. ' 

Probably oak bark is specific in its action, but it acts chiefly, 
not by contracting tissues and blood vessels, although it may do 
this in a measure, but by refusing to be absorbed readily, and by 
remaining in the tissues until the stimulation and irritation set 
up by it, the alcohol, and the ether shall have produced an 
inflammation that shall compel the tissues to consolidate. This 
is readily proved by the fact I have often mentioned, that when 
I have injected the superficial integuments around the rings, the 
dark appearance and consolidated structure will remain for 
months, and even years. It also offers an additional reason for 
" reinforcing " these tissues as I do, to sustain the rings, and act 
as a constant compress. This specific action is the reason why 
this operation does not have recidive more frequently. 

For the benefit of any who wish to perform this operation, the 
following concluding observations are given. 

In small hernial or bubonoceles occurring in patients from 
four to twenty years of age, who otherwise enjoy good health, 
an injection of iodine, sulphuric ether, alcohol, oak bark, or, as 
one surgeon writes me, of sulphate of zinc — fifteen grains to the 
ounce of water — will generally effect a cure, if all the directions 



3S2 HERNIA. 

I have given are carefully followed out in every particular. In 
very large herniae, or those of long standing, the cure will be 
.more difficult of accomplishment, and we cannot expect a per- 
manent cure so confidently as in the simpler cases of small and 
recent herniae. The cure can be accomplished only by impress- 
ing upon both the patient and ourselves that the action of any 
fluid we may elect is only the primary step in the operation ; 
remembering that with a stimulating fluid we are hastening, 
with some degree of certainty, what might take place more 
slowly under the wearing of a proper truss. See page 321. 

These large and old hernias may require several injections 
before we effect a cure. The injections should be repeated once 
in three to six or eight months, or upon the least signs of any 
weakening of the parts. As soon after the operation as possible 
a good truss of steel, or an elastic bandage with proper pads, 
should be applied. This should be worn constantly while in the 
upright position. The patient should wear a truss, and remain 
under our observation for a year or more, and be carefully exam- 
ined from time to time, so that successive irritation and inflam- 
mation of the parts may be made, if necessary, either by gentle 
pressure or by a new injection if needed. If we treat our cases 
with judgment, taking all possible care and pains, we shall by 
perseverance be rewarded with the cure of many unpromising 
cases ; but if, according to the method of one operator, we inject 
only a little fluid, use only a cloth bandage and discharge the 
patient as cured after a few days have elapsed, we shall be most 
certainly disappointed. I feel warranted in saying from my 
experience, that if our operation be successful in keeping up the 
hernia for a period of six months, w r e may have great hopes that 
adhesions have formed so firm and solid that they will, as is 
shown on page 199, continue to grow more firm and consoli- 
dated. 

As I have already said upon page 175, I have exercised great 



RESUME AND CLINICAL REPORTS. 3S3 

care in the selection of my patients ; I have not endeavored to 
see how many cases I could operate upon, but I have all the 
time been careful to see both how much can be done in the way 
of effecting a permanent and trustworthy cure of hernia, and 
how much we can reasonably expect of the method of sub- 
cutaneous injection in effecting this desired cure. I have there- 
fore rejected many cases which might possibly have been cured, 
but upon whom I thought the operation of injection would not 
be markedly successful. I have done this for three reasons : 
because some of the patients were aged or in poor health ; be- 
cause others had been ruptured so many years that even with 
our improved method, mentioned below, we could hardly hope 
for success ; and, finally, because some of the patients did not 
seem sufficiently intelligent to appreciate the importance of the 
after-treatment, and the fact that the greater part of our success 
really depended upon them in obeying our instructions most 
implicitly. 

On page 180, I have said that I hoped at some future time to 
develop a method of operation which should give us a better 
success in the case of old and laro-e rings which have become 
fused into one, and which produce little exudation of plastic 
lymph. I have fulfilled my expectations much better than I 
then could even hope. In the first place, I can inject much 
more of my new injecting fluid (see page 372), on account of 
the tincture of veratrum viride that is in it, while by the strong 
rubber compress (mentioned under Bandages, page 374) I can 
keep the parts in close apposition, for a time varying from three 
to thirty days, until adhesions take place sufficient to bind the 
fibres of the rings together. In the second place, to persons of 
great obesity, and to those who have hernise not easily retained, 
I apply a piece of elastic rubber tubing, some five or six feet 
long, just below the hips, after the method of Esmarch in his 
bloodless operations. After tying it tight around the groin, I 



384 HEKNIA. 

roll it over the abdomen, pressing upward thereby all loose 
tissue, together with the peritoneum and hernial protrusion, so 
that they are out of harm's way during the operation. I have 
found this arrangement convenient both to the patient and to 
the operator, and it has enabled me to undertake cases with con- 
fidence that I should previously have rejected or accepted only 
with hesitation. 

I have said already many times, and I now finally repeat, 
that we cannot foretell with certainty what success may attend 
our efforts to effect a cure ; we can only wait upon and assist 
nature. If, then, we ourselves can only hope, but cannot know 
what will be the result, it is very unprofessional, and savors of 
the charlatan, to assure any single one of our patients that we 
can certainly cure them. On the other hand, it is likewise as 
unreasonable that patients should expect us to give such posi- 
tive assurances. 

No surgeon, even in the operations that have been performed 
from time, I was about to say, immemorial, would venture to 
say more than that some operation seemed to be necessary for 
the patient's happiness, or even life, and that this or that opera- 
tion in the surgeon's candid opinion was the best one to be em- 
ployed. Yet in the cure of hernia, patients seem to expect us 
to " warrant a certain cure without failure ; " and, stranger still, 
physicians of good standing can be found who will not only 
promise such a cure, but who seem to praise faintly an operation 
which will not allow of such rash assurances. 

All of my patients, at least, clearly understand before I operate 
upon them that this is my position, and that I will never in any 
case of operative surgery, no matter what it be, guarantee a cure. 
That, however, I have the greatest confidence in the operation 
and its value the following cases will show ; according to their 
record, it has been found by actual calculation that 92 per cent 
of all operated upon have resulted in positive and permanent 



R£SUjVI£ AND CLINICAL REPORTS. 385 

cures. Out 'of about one hundred and fifty-six cases reported 
and well authenticated, there have been only twelve failures. 

It will be seen that I report only cases of genuine hernia, and 
that there is no mistake about their character, kind, and severity; 
so that we may with confidence know just how much reliance to 
place upon the operation. 

In my first twenty-nine cases I have already said I had some 
failures, and on page 199 I have attributed these partial failures 
to both the imperfect instrument and the crude injecting fluid. 
In my last cases, out of more than the same number, I have not 
had a single failure, — unless, possibly, in the case of a physician, 
upon whom I operated for a very severe case of oblique inguinal 
hernia, and who was suffering at the time from general debility 
and dyspepsia. The case was a success at the time of opera- 
tion, but no very great length of time has since elapsed, so I 
cannot yet be confident of a permanent cure. 

In a treatise on hernia like the present one, I cannot think of 
giving, or even attempting to give, the names of all who are now 
operating by the injection method, nor a full record of the cases 
operated on. From the reports I have from the instrument 
makers, that " they are hard pressed to manufacture my instru- 
ments fast enough to fill the orders for them," I should judge, 
however, that the number of medical gentlemen who are now 
employing the method is no small one, to say the least. Many 
of them have corresponded with me, and with some of them 
I am personally acquainted. I mention especially Drs. C. P. 
Bancroft, of Boston, Mass., W. A. Byrd, of Quincy, 111., H. I. 
Jones, of Scranton, Pa., H. S. Greeno, of Kansas City, Missouri, 
and "W. H. Heath, of Buffalo, New York, and know that they 
have operated successfully by the subcutaneous method. 

I shall therefore give only a few characteristic cases, first from 
the practice of Dr. H. S. Greeno, of Kansas City, Missouri, then 
a few reported by Dr. W. H. Heath, Assistant Surgeon United 



386 HERNIA. 

States Marine Service, attached to the Hospital at Buffalo, N. Y., 
and shall conclude the list by a few of my own which are 
deemed the more interesting, taken not in order but at random. 

CLINICAL REPORT OF CASES OPERATED ON FOR THE 
CURE OF HERNIA BY THE METHOD OF SUBCUTANE- 
OUS INJECTION. 

CASES REPORTED BY DR. H. S. GREENO, OF KANSAS CITY, MO. 

Mr. J. E. E., Fort Smith, Ark, aged twenty-seven, November 
20th, 1879, right inguinal oblique hernia, eleven years' standing; 
left inguinal oblique, fifteen months' standing. Unable to retain 
the bowel on right side with truss, and complained of much 
pain and suffering. Operated November 22d, on right side, 
with Dr. Heaton's instrument and simple extract of Quercus 
alba, with usual dressing. December 3d, dressing removed ; ex- 
amination indicated cure. Then operated on the left side, Decem- 
ber 12th. Eemoved dressing ; found left side solid. In a few 
days there was. a slight protrusion of bowel through internal ring 
of right side. The patient being unable to remain longer, I in- 
troduced a few drops of the solution directly into the internal 
ring. On the third day applied a double elastic spring truss 
and the patient left for his home, being instructed not to remove 
the truss for sixty days. Six months after he reported himself 
cured, having abandoned the truss. 

Case 5. — J. B., Buffalo, Ark., aged sixty-two, direct inguinal 
hernia, which he was unable to retain with a truss ; complained 
of much pain at times. Operated December 15th, 1879. Eesult 
partly successful. Operated the second time January 10th, 
obtaining a perfect cure. 

Case 9. — Wm. McA., Independence, Mo., age seventy- 
three, double oblique inguinal hernia, right side, twenty-one 
years; left side twelve years. Had worn truss continuously for 



K£SUM£ AND CLINICAL REPORTS. 387 

twenty-one years. Operated, March 24th, on right side, using 
fluid as improved by Joseph H. Warren in his work on Hernia, 
and applied rubber bandage with compress. 

Usual symptoms followed ; third day fever entirely subsided. 
On the tenth day operated on the left side. Fever and increase 
of temperature much less than after first operation. On the 
twenty -first day after first operation, removed the bandage. Had 
the patient stand up and cough, and let him walk about as much 
as he felt able. Found a very slight tumor on internal ring on 
right side. Applied a double elastic spring truss to be worn a 
month. I did not deem it necessary to operate the second time, 
trusting to the continuous wearing of the truss to complete a 
cure. At the present time the patient is perfectly cured of both 
hernias. 

Case 11. — J. W. J., Kansas City, Mo., brought to me his 
little daughter, aged eleven, having right inguinal hernia of six 
years' standing. Operated March 26th, 1880 ; cure perfect. 

Case 1J. — Mr. C, Kansas City, Mo., aged forty, left oblique 
inguinal hernia, eleven years' standing. The hernial opening 
was very large, and the protrusion could not be retained with a 
truss. Operated with Dr. Warren's instrument and fluid, sub- 
stituting for the bandage a double elastic spring truss, after re- 
moving the wooden pads, and supplying their places with muslin 
folded to many thicknesses. This I found more convenient than 
a bandage. The elastic belt, broad front pad, and perfectly- 
adjustable thigh straps have proved all that may be desired as a 
dressing, and is worn with as much comfort after the operation 
as any truss or bandage I have been able to procure. 

Case 15. — Mr. E., Kansas, aged twenty-five, umbilical hernia 
of recent standing; operated April 15th, 1880. 

Case 16. — Mrs. B., Fort Smith, Ark., aged fifty-six, left fem- 
oral hernia, six years' standing. A large and irreducible tumor, 
which I diagnosed as omental, and which, after several trials, I 



388 HERNIA 

succeeded in reducing. I then operated for radical cure, with 
satisfactory results. 

Case 17. — Mr. McD., Kansas City, Mo., aged thirty-six, 
oblique inguinal hernia of right side of sixteen years' standing. 
Operated April 24th, 1881 ; successful. ■ 

Case 18. — Mr. C, Iowa, aged thirty-two,, left inguinal hernia, 
twelve years' standing. Operated May 2d, 1880. On the twelfth 
day patient returned home cured. 

Case 20. — Dr. W., Kansas City, Mo., right inguinal hernia, 
nine years' standing. Operated May 20th, 1880, obtaining a cure. 

Case 30. — Mr. C. S., Kansas City, Mo., child, four and a half 
years old, congenital scrotal hernia right side. Operated August 
23d ; cure complete. Wears no truss. 

Case 31. — Mr. D., Kansas City, Mo., boy, eleven years old, 
direct inguinal hernia on right side. Bowel had descended into 
scrotum ; parts were swollen, and I had much trouble in return- 
ing the hernia. Operated August 24th. 

Case 33. — Mr. McQ., Ottona, Kansas, aged forty, right ob- 
lique inguinal hernia ; operated August 25th, 1880. Patient 
returned home on the fifth day, refusing to remain longer. The 
inflammation was very slight, and there was no fever. This case 
was not cured, owing to the very slight disturbance produced by 
the operation and the patient's refusal to comply with my 
instructions. 

Case 34. — Mrs. D., Kansas, right oblique inguinal hernia, 
twelve years' standing. Patient had an excess of adipose tissue. 
Opening quite large and hernia retained with much difficulty. 
Operated August 28th. Eight days after, in spite of all I could do 
to the contrary, my patient would return to her home, some two 
hundred miles from the city. I expressed my fears that the cure 
might not be complete without another operation. She promised 
to return after a few months if the operation did not prove suc- 
cessful. Several months after, I received a letter from her 



RESUME AND CLINICAL REPORTS. 389 

claiming that she was not cured, and censuring me quite severely 
for not having made a cure. Such failures will occur in every 
surgeon's practice, but cannot be attributed to any fault in the 
operation or operator. 

Case 36. — Mr. W., Kansas City, Mo., aged fifty-two, right 
oblique inguinal hernia. Operated August 28th, 1880 ; cure 
perfect. 

Case 40. — F. S. H., Lawrence, Kansas, aged twenty-eight, 
direct inguinal hernia on right side, rings very large and could 
not be retained with a truss ; bowel descended into scrotum, and 
was a source of great annoyance. After a second operation, the 
patient was discharged cured. 

Case 51. — Mr. E. T. P., Kansas City, aged fifty-six, inguinal 
hernia of fifteen years' standing. Operated January 3d, 1881, ob- 
taining a permanent cure. 

Case 53. — Mr. B. ; Lawrence, Kansas, son, four and a half 
years old, congenital hernia of left side. Injected dilute extract 
of quercus alba ; this operation failed. Six weeks after, 1 injected 
a stronger solution, using more care in the after treatment. 
From present indications I have no doubt as to the cure. 

Case 85. — Mr. H. H., Ellis, Kansas, aged fifty-six, double 
inguinal hernia, right side, sixteen years ; left side, eight years. 
Twelve years before, the bowel on the right side descended into 
scrotum, since which it has been impossible to retain it with any 
appliance. Bowel remained almost constantly in the scrotum. 
The tumor was as laro-e as a new-born infant's head. When 
reclining, the hernia could be reduced with much difficulty ; but 
on resuming an erect position, the bowel would, to use the 
language of my patient, " shoot out " in spite of all efforts to 
retain it. The left side w 7 as not quite so bad. His condition 
was truly deplorable. He suffered much pain, and experienced 
a dragging sensation upon the stomach, spleen, and diaphragm. 
After moving the bowels freely with oil the day previous, I 



390 . HERNIA. 

operated May 22d, 1881. I found the sac on the right side ad- 
herent, and it was impossible to reduce it by any amount of 
manipulation. There was much thickening of the walls of the 
sac, so in this case it was quite out of the question to pass a 
needle into the rings without penetrating the sac. Either the 
knife must be used and the sac must be dissected away and 
returned within the cavity of the abdomen, or the irritant be 
deposited within the walls of the sac. The patient was deter- 
mined to submit to an operation, life to him being intolerable in 
his present condition. I therefore disregarded the sac, and 
passed the needle through it as near the upper margin of the 
ring as possible/depositing at least thirty drops of the irritant 
within the ring, taking care that the fluid should be Avell dis- 
tributed. Used wet compress and usual dressing. The inflam- 
mation was greater than in any other previous case, and the 
fever continued until the fourth day before declining. By the 
sixth day fever was absent and inflammation rapidly subsided. 
On the twelfth day, removed dressing ; patient stood up and 
walked around, there being no protrusion of bowel. I then 
operated on left side. Sac was readily reduced. Had no trouble 
in introducing the needle ; injected fifteen drops of fluid. 
Eight days after, and twenty days after first operation, removed 
the dressing and found the parts solid. Coughing and straining 
had no effect on the hernia? on either side. On the twenty-fifth 
day, patient returned home perfectly cured 'and much elated. 

Case 86. — Mr. J. W. H., Baldwin City, Kansas, aged nine- 
teen, direct hernia on left side ; twenty-four years old. Had 
varicocele and could not wear a truss. Operated May 27th, 
1881. Inflammation quite severe, with much soreness. Pulse 
110, but declined on third day. Case discharged cured on the 
tenth day. 

Mrs. B., Texas, aged fifty- two, irreducible femoral hernia on 
right side, had been irreducible for six years ; wore a truss with 



RESUME AND CLINICAL REPORTS. 391 

great inconvenience, and more or less pain. The tumor was 
about the size of a small hen's egg ; it was impossible to reduce 
it by taxis, although I made several efforts at different times, and 
I concluded to operate with the knife. Contents of the tumor 
were omental. I was obliged to remove a portion of this before 
I could return it into the cavity of the abdomen. I followed Dr. 
Heaton's suggestion of not ligating the neck of the protruding 
mass before removing it. The hemorrhage was slight and easily 
controlled by compress. This case gave me but little trouble, 
and the recovery was perfect, although at one time I had fears 
of secondary hemorrhage, and fully made up my mind that should 
I ever again amputate a portion of the omentum I should first 
ligate the neck. Six months after the patient returned home, she 
wrote me that she was perfectly cured. 

To sum up my cases, I submit the following, which is really 
as near the facts as it has been possible for me to obtain knowl- 
edge. Some of my cases have failed to answer letters of inquiry 
addressed to them, which I take as a very good indication that 
they are satisfied with their treatment, or I should bear from 
them. 

Total number of cases operated on . . 97 

Cases reported cured ....... 91 — 93.81 

Failures 6— 6.19 

100. 
Number reported who have abandoned 
the use of trusses 56 

The failures were of my first cases, and were mainly from 
my neglect in carrying out details and giving proper attention 
to after treatment. I have had no failures lately, and do not 
now expect any in the future, as I confine myself to Dr. 
Warren's improved instrument and more stimulating fluid. 



392 HERNIA. 

CASES REPORTED BY DR. W. H. HEATH, OF BUFFALO, W. Y., 
ASSISTANT SURGEON, UNITED STATES MARINE HOSPITAL SER- 
VICE. 

Case 1. — The irritant was deposited by accident in the 
areolar tissue around the cord, which from pressure of the her- 
nia had been spread out and displaced almost beyond recogni- 
tion. This accident resulted in the formation of an indurated 
mass, occupying the site of the cord, and apparently very indo- 
lent; later it became larger with fluctuation, and was tapped, 
yielding two ounces of clear fluid. A second enlargement oc- 
curred, and pus was found and withdrawn. At this period, the 
mass was very tender and disposed to inflame, but did not ; the 
patient left soon after with this indurated mass (about the size of 
an egg) occupying that region, and resumed his work as a laborer. 
He was a stupid, middle-aged Irishman, that had been sent to 
me, ' and had Bright's disease, which fact I was not informed of 
until afterwards. Singular to say, the hernia has not since de- 
scended, the mass evidently blocking the way, in part at least. 

Case 2. — G. P., aged thirty-two years, native of France, was 
admitted with acute bronchitis. An oblique reducible inguinal 
hernia was discerned of some seventeen years' duration. He 
consented to an operation reluctantly, and the result was a fail- 
ure. The ring was comparatively large and patulous, and should 
have had a second wetting with the fluid ; but he would not 
give his consent. He contributed nothing himself to aid in a 
successful issue in the way of lying on his back, and keeping 
quiet, and prognosticated in advance, that it was impossible to 
cure him ; and he did n't care, etc. I think this had something 
to do with the result. 

Case 3. — E. C, sixty-one years, native of Canada, with a double 
reducible inguinal hernia of twenty-three years' standing, came in 
to have one side operated upon, and, if successful, would return 



RESUME AND CLINICAL REPORTS. 393 

in the fall to have the other side operated upon. Left hospital 
apparently cured, and promised to let me know by mail if it 
descended again. I have not heard from him since. He was 
under my observation eight weeks, having been detained in the 
hospital with neuralgia and some abdominal trouble. 

Dr. Heath says, " I think it requires more care than would at 
first appear, and is one of the most rational of the many methods 
advised. I am firmly of the opinion that it is a step in the 
right direction." 

Simple as it all appears, it requires considerable care and 
dexterity ; the cord, which must be pushed aside, may be dis- 
placed and in part overlie the sac, which may itself be irredu- 
cible. The direction of the canal and position of internal ring 
changed, the' possibility of transfixing one of the pillars, wound- 
ing the cord, or entering the abdominal cavity, are all to be 
remembered and avoided. The attention to every detail in oper- 
ating, adjusting the compress and bandage, and the after-care 
are so important as to largely determine the result in most 
cases. An hour or so, therefore, in the dissecting-room, with a 
long needle, would not be misspent, but would aid to familiarize 
a beginner with the points most important to find, or as far as 
possible, to avoid. 

This method I have resorted to twelve times with one failure 
(I believe due entirely to a nurse's carelessness), and one acci- 
dent where I deposited the irritant in the areolar tissue of the 
cord, which from pressure of the hernia had been spread out and 
displaced, almost beyond recognition. Nine of the cases I con- 
sider permanently cured, and two are yet under observation in 
my wards. All the cases were of the oblique reducible inguinal 
variety, eight of five years' standing, one of seventeen years', one 
of twelve years', two over ten years'. 

In no case did I observe a single bad symptom, elevation of 
temperature, or pulse rate, and but little, if any, of what may 



394 HERNIA. 

properly be termed suffering ; and, with the exception mentioned, 
every case left my hands, after keeping them as long as I could, 
apparently cured. I say "apparently cured," because the standing 
argument against the permanency of the result at once is raised; 
and I cannot say positively, beyond peradventure, that they are 
permanently cured, for they are beyond any observation now. 
Two of the men I had the good fortune to see and examine some 
six months after, and in both the inguinal canal was closed per- 
fectly, and the protrusion had never appeared since leaving the 
hospital. One of them had subjected his case to a pretty severe 
test, having worked as coal-heaver on a southern steamer ever 
since. I do not recall what kind of work the other had been 
engaged in ; but, as he was an ordinary sailor, I do not doubt the 
radical cure was strongly tested. 

CASES REPORTED BY THE AUTHOR. 

Case . — Mr. M., aged twenty-eight, direct inguinal hernia 
on right side for five years. Could not bear a truss on account 
of the tenderness of the parts, Operated October, 1879, using 
fifteen drops of Formula B. For six or eight hours after the in- 
jection, he had fever and increase of temperature to 99, pulse 80. 
This subsided to normal on the following day. The parts oper- 
ated on were considerably swollen, and for three days compresses 
of cold water were applied externally and one eighth of a grain of 
morphia given internally once every six hours. On the eighth 
day, an active cathartic was administered. The opening, which 
before would admit the ends of two fingers, was now fully oc- 
cluded. Several medical gentlemen saw the case both before 
and after operation. July, 1881, he is still free from hernia, 
and can go without his truss. 

Case . — Mr. J., aged thirty, oblique inguinal hernia on 
right side extending into scrotum. It had existed for six years. 
The opening in the rings was one inch by three quarters of an 



R£SUM£ AND CLINICAL REPORTS. 395 

inch. Operated on him December, 1879, with fifteen drops of 
Formula B. The inflammation was sharp, and extended up as 
high as the crest of the ileum. There was some increase of tern- 
perature for about four days, but on the seventh day the bowels 
were moved by a laxative and a truss applied. On the twelfth 
day he was discharged, cured of his hernia. I have no report 
from the patient himself, but have heard elsewhere that he is 
still free from his hernia. 

Case . — Mr. M. J., aged sixty, large oblique inguinal 
hernia on right side extending into scrotum. It had become 
strangulated. It came on while stepping down from the side- 
walk, and the first noticeable symptom was pain and smarting 
in the umbilical region, together with considerable nausea. As he 
had been suffering for some time from indigestion, he did not think 
very much of it at the time. But the pain began to grow in- 
tense, the action of the heart became feeble, and beads of cold 
sweat stood upon, his neck and forehead. I succeeded, in De- 
cember, 1879, after considerable difficulty, in reducing the pro- 
trusion by taxis, and on the following day the tenderness and 
swelling of testicle had so .far abated that I operated by the sub- 
cutaneous method, injecting ten to fifteen drops of Formula C. 
There was but little increase of temperature after the operation, 
but a smart local inflammation around the cord and rings. His 
extremities felt so cold that hot applications were made to them. 
In three weeks' time he returned to his office, wearing a com- 
press, which he afterward changed for a light truss. After 
wearing this for a few months he abandoned it, and is now with- 
out any support. 

Case . — Mr. M., aged thirty-two, oblique inguinal hernia 
on right side of five years' duration, caused by rowing. Protru- 
sion very slight. Operated March, 1880, injecting fifteen drops 
of Formula B. Fever very slight, and continuing three days ; 
temperature 99, accompanied by active inflammation about the 



396 HERNIA. 

rings. The opening in the external ring was three quarters of 
an inch by five eighths of an inch. It was an irritable hernia, 
the truss by its pressure causing pain and tenderness through 
all the parts, so that it could not be worn conveniently. On the 
fifth day, the bowels were moved by a mild laxative. On the 
tenth day, he was discharged, wearing a compress and bandage. 
He wore a truss for six months, but has been able to go without 
truss or support of any kind for about a year, with no signs of 
return of hernia. 

Case . — Mr. H., aged thirty-two, direct inguinal hernia on 
left side, caused by exertions as a fireman. Operated by the 
subcutaneous method April 8th, 1880. Protrusion very large and 
prominent. Opening in rings, three quarters of an inch by one 
inch, running to a sharp point at both ends, or diamond-shaped 
with greatest diameter longitudinally. Injected twenty drops 
of. Formula B. We had an abundant effusion of plastic lymph 
and a perfect occlusion of the rings. He suffered but little 
general fever, and hardly any increase of temperature, but had 
an intense soreness about the rings, and a prominent swelling, 
which began on the second day and lasted until the sixth. On 
the seventh, a mild laxative moved the bowels, and on the tenth 
day, he was discharged cured, wearing a truss of very gentle 
pressure. He wore it for eight months, and since then has 
been without any support. 

Case . — Mr. D., aged forty, double inguinal hernia, oblique 
on left side and direct on the right. Been ruptured fifteen 
years. The ring on left side was one inch by three quarters of 
an inch. The right ring was one half inch by five eighths. Pro- 
trusion when in erect position was very slight on right side, but 
large on the left side. Operated October, 1880, assisted by Drs. 
H. O. Marcy and Bancroft of Boston, and my Assistant, Willard 
E. Smith, Medical Student. I used Formula B, which contained 
a little less ether and alcohol and a little more of the Fl. Ext. of 



RESUME AND CLINICAL REPORTS. 397 

Oak Bark. On the seventh day, the bowels were moved by in- 
jection ; the swelling and inflammation, which was active on 
both sides, had fully subsided ; on the twelfth day he was al- 
lowed to rise from bed and be "about the house," wearing a 
bandage and compress. Both rings were perfectly occluded and 
the herniae well retained. On the fifteenth day, a small super- 
ficial abscess, like that seen after the injection of ergot, appeared 
on the right side. This did not extend deeper than the super- 
ficial integuments. It was thought to be caused by too severe 
pressure of the perineal band, and it annoyed him for two or three 
weeks by discharging a sero-sanguineous fluid. A light double 
truss was then ordered, and he resumed his occupation as a 
finisher of microscopes. On June 30th, 1881, I examined him. 
He is free from hernise, and can go without his truss. 

Case . — Mrs. T., aged thirty-five, large femoral hernia on 
right side. It had been strangulated some six weeks previous 
to the time when I saw her. Her physician was Dr. A. L. Nor- 
ris, of Cambridge, Mass., who had succeeded in reducing it by 
taxis after great efforts. He was assisted by Dr. D. M. Edgerly, 
of the same city. I operated by subcutaneous method in Jan- 
uary, 1881, using from fifteen to twenty drops of Formula C. I 
was assisted by Drs. Norris and Edgerly, and by Dr. E. L. White, 
of Somerville. The temperature never rose to 100, as I was 
informed by Dr. Nbrris, under whose care I had left her. The 
injection set up in the femoral canal an active inflammation, 
which lasted for about a week. On the fifteenth day from the 
time of operating she was discharged, perfectly cured of her 
hernia, and was ordered to wear an elastic bandage with a sole- 
leather pad in front, shaped like an abdominal supporter. This 
apparatus was devised by a gentleman who himself has suffered 
from hernia. I have found it very effective to apply after these 
operations, while the parts are sensitive, and do not bear well 
the compression of an ordinary spring truss. It has the addi- 



398 HERNIA. 

tional advantage that it can be worn night and day without dis- 
comfort. On July 6th, 1881, I examined her in company with 
Dr. Norris, and found that she still remained free from her 
hernia. I would say that Dr. Norris caused the patient to 
cough, and bear down, and make other efforts, which satisfied us 
of the perfect retention and cure of the hernia. Owing to her 
excessively large and broad hips, I thought it would be safe for 
her to continue to wear the support until autumn, when she 
could abandon it. 

Case . — Mrs. E., aged fifty-five, ruptured at childbirth, 
thirty-three years ago. Very large umbilical hernia. The size 
of the opening was two inches by an inch and a quarter, and 
was of a long oval shape ; the lower portion extended clown into 
the rectus muscle. The umbilical dimple had entirely disap- 
peared on account of the enormous protrusion, which in the 
erect position was nearly as large as the head of a child a year 
old. Operated by the subcutaneous method February, 1881, 
assisted by my son, C. Everett Warren. I used nearly a drachm 
of Formula C. I made my puncture just to one side of the centre 
of the umbilical cicatrix and below it, sweeping my needle 
around and distributing my fluid well on the outer edge of the 
umbilical ring. 

For the first forty-eight hours the temperature and pulse were 
normal. At the time of operation the pulse had been reduced 
from 70 to 55, and it was found necessary to apply hot applica- 
tions to the feet. On the third, fourth, fifth, and sixth days the 
pulse stood at 80, and the temperature at 99. She had a pretty 
smart local inflammation, and complained of considerable pain 
in the back, owing, probably, to the constrained position of lying 
upon it. There was very great curvature of the dorsal and 
lumbar portion of the spine, so that a large pillow could be in- 
serted under the small of her back easily ; thus her abdomen 
was thrown forward and presented a very prominent appearance. 



R£SUM£ AND CLINICAL REPORTS. 399 

She was very large, and weighed about one hundred and eighty 
pounds. She continued restless after the second night ; morphine 
was given, but this producing nausea, we then gave her bromide 
of potassium, which seemed to be sufficient to produce the 
desired rest and sleep. 

On the eighth day the bowels were moved by a slight laxative, 
and the patient was allowed to sit up in bed and to lie on her 
side. The local swelling and inflammation extended in a circu- 
lar direction, with a radius of seven or eight inches. Compresses 
of cold water were applied, and on the tenth day the swelling- 
had so far subsided that we could pass a rubber band three 
inches wide twice around her body, giving us an equal pressure. 
This compress was continued for four or five clays. It was 
applied over the linen bandage which had already been put on. 
At the expiration of this time, sufficient exudation had taken 
place, and the vast umbilical ring was found to be fully occluded 
and the former hernial protrusion entirely retained. This exu- 
dation and inflammation caused a thickening of the integuments, 
which lasted for three or four weeks. As it gradually shrunk 
and contracted, the original umbilical cicatrix again made its 
appearance, and she has to-day as perfect an umbilical dimple 
as she had when a babe. She is now (July 1, 1881) able to go 
without any truss or bandage, and I, together with her, feel as 
confident that she is as perfectly free from her hernia as she 
was before her rupture. Entertaining such confidence, she is to 
spend her summer among the White Mountains, going without 
any support whatever. She regrets very much that she did not 
have a photograph of the hernia taken, to show the contrast 
between her condition then and her normal condition now. 

It will be seen that this protrusion was one of the largest of 
this variety that we meet, I fully . expected to have to inject 
several times before attaining the desired result, but by taking 
great pains and care at the time of operating, by distributing the 



400 HERNIA. 

fluid as equally as possible all around the ring, I succeeded be- 
yond my expectations in making a radical and complete cure by 
a single injection. 

Case . — Mr. H., aged thirty-five, oblique inguinal hernia 
on left side of two or three years' standing. Operated in April, 
1881, with the assistance of Dr. B. 0. Kinnear, of Boston, and 
Mr. Cox, medical student. I injected of Formula C, twenty 
drops. The hernial opening was very long and irregular oval, 
one inch by one half inch, the pillars on the outer side seem- 
ingly torn. For the first four days he had slight increase of 
pulse and temperature, the latter being 98.5, and never extendi 
ing over 99. On the fifth and sixth days a swelling of two fingers' 
breadth over the external oblique, extended from the seat of 
operation up to the crest of the ileum. This swelling gradually 
subsided, leaving a hard, cord-like feeling, which diminished 
slowly, but which will remain for a number of months or even 
years. It will give him no trouble, but will be of great assist- 
ance in closing the rings and retaining the hernia. I presume 
it was caused at the time of operation by a small stream from 
the instrument escaping upon the surface of the muscle as I 
withdrew my instrument. I can account for it in no other way. 
There was no other complication, and the case made a remarkably 
rapid recovery. 

So perfect was this, that, with the support of the elastic truss 
which I have before mentioned, he visited Cape Breton Island, 
and told me that he went over mountains and valleys, and 
waded through streams. After returning home, he lifted seven 
hundred pounds in weight in the office of the doctor who had 
assisted me, and then called upon me to show that the operation 
was a perfect success, and that he was cured from hernia. When 
we consider that all this was done within the brief space of one 
month after the time of my operation, it seems almost like a 
fairy tale, and would be hard to believe, if it were not well 



k£sum£ AND CLINICAL REPORTS. 401 

authenticated by the physician in whose office he lifted the 
weight. 

I myself had some reasonable doubts that such a thing could 
be possible, but on asking the physician found that the feat had 
really been performed. I think the reader will agree with me 
in assuring the man that he is permanently cured of his hernia. 

Case . — Dr. H., aged fifty-nine, oblique inguinal hernia on 
right side. Has existed more than two years. The hernia was 
prevented from descending into the scrotum with great diffi- 
culty and by means of a truss. Operated by the subcutaneous 
injection in April, 1881, using Formula C, assisted by Drs. Daniel 
Chaplin and son, of Bridgewater, Mass. The operation was not 
very painful, Dr. H. said, but the smarting of- the injected fluid 
was " liquid fire for a minute or two." This soon subsided, 
leaving a throbbing sensation in the parts, which gradually 
passed away. The opening at the ring was abont an inch and 
a half long by five eighths wide, and was long and irregularly 
oval. He had little constitutional disturbance except a rapid 
reduction of the action of the heart, and cold extremities to 
which hot bottles were applied. He was slightly feverish for 
four or five days, with considerable tenderness about the parts 
operated upon. The greatest suffering was from the constrained 
position of lying on his back and from considerable flatus of the 
bowels. For the latter he ate freely of "ginger snaps," with 
sufficient morphine at night to cause rest. He was able to be 
up on the eighth or ninth day, with a perfect retention of the 
hernia. An elastic truss was applied, which he is still wearing. 

Case . — Mr. W., aged twenty-one, oblique inguinal hernia 
on right side. Patient sent to me by Dr. G. W. Bullard, ot 
Vermont. Operated June, 1881, using of Formula C, about 
ten or twelve drops. The sensation of smarting was very sharp 
for four or five minutes. The temperature never rose to 100, 
nor the pulse above 88. The local inflammation and soreness 



402 HERNIA. 

were considerable ; they were increased by my reinforcement of 
the external integuments, which left a prominent swelling at the 
time of his discharge, some twelve days after the operation. The 
rin^s were occluded and the hernia well retained. He was 
ordered to wear a truss for six months. One thing I notice in 
hernia of short duration is, that the smarting from the injected 
fluid is more intense, and that the amount of fluid necessary is 
smaller than in cases of longer standing. 

Case . — Mr. L., aged twenty-three, direct inguinal hernia 
for five years. Operated June, 1881, by injecting twelve to 
fifteen drops of Formula C. He passed through the usual phases, 
with the exception that his attendant, Dr. Stevens, of North 
Cambridge, was obliged to draw his urine for two days. On 
July 1, 1881, I found the rings firmly united, and the hernia 
retained. 



BIBLIOGRAPHY. 



BIBLIOGRAPHY OF HERNIA. 



A. 

Abernethy, J. J. Inguinal Hernia. Amer. Journal Med. Sciences. Yol. 

XL, p. 31. 1832. 
Acret, G. S. Treatise on Hernia. London, 1835. 
Agnew 3 D. Hayes. Surgery. Last Edition. 
Albers, J. E. H. Pathologische Anat. 
Albinus. Tab. Muscul. 

Anderson, W. System of Surg. Anat. 1822. 
Arnaud. On Hernias. 1748. 

Mem. de Chir. Paris, 1743. 

Observations sur plusieurs Hernies. 
Atlee, W. E. Case of Strangulated Hernia. Amer. Journal Med. Sciences. 
Vol. XXXVIL, N. S., p. 275. 1859. 

Balfour. New Mode of Taxis in Med. and Pliys. Journal. November, 1824. 

Bell, B. System of Surgery. Vol. I. 

Bell, C. Surgical Observations. Part II. London, 1816. 

Benevoli. Dissertazioni Chir. Tomo I. 

Bernard, Claude. Medecine Operatoire. 1866. 

Bertrandi. Traite des Operations. Tomes I. et II. 

Bicliat, X. Anat. Generale. Paris, 1830. 

Bigelow, H. J. Inguinal Hernia (injection). Boston Med. and Surg. Jour- 
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Billard, C. De la Membrane Muqueuse Gastro-Intestinal. Paris, 1825. 

Birkett, John. In Holmes's Surgery. 2d Ed. Vol. IV. 

Blackman, G. A. Wurtzer's Operation. Amer. Journal Med. Sciences. Vol. 
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406 HERNIA. 

Blackmail, G. P. Reduction of Strangulated Hernia " en masse." Amer. 
Journal Med. Sciences, Vol. XII., N. S., p. 336, 1846 ; N. Y. Journal 
of Med., Vol. V., p. 367, 1850. 
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Bose. Animadvers. de Hern. Inguin. 

Bourgeryet Jacob. Traite Complet de l'Anatomie del' Homme. Paris, 1830. 
Braitliwaite's Retrospect. 
Brendelius. De Herniarum Natalibus. 
Breschet, G. Considerations sur la Hernie Pemorale. 
Brugnone. Dissert, de Test, in Poetu posit. 

Briiningliausen, H. J. Unterricli iiber die Briiche, etc. Wurzburg, 1811. 
Bryant, Henry. Boylston Prize Essay. 1847. 

Bryant, Thomas. Analysis of 126 Cases of Hernia followed by Death. Guy's 
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Clinical Surgery. Part IIL 

Practice of Surgery. Vol I. 
Butcher, Rich. G. Oper. and Conserv. Surgery. 



Callendek, Geo. W. Anatomy of Pemoral Hernia. London, 1863. 
Campbell, H. P. Strangulated Ventral Hernia. Southern Med. and Surg. 

Journal. Vol. XIII., N. S., p. 131. 1857. 
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Chadwick, James R. Rare Porms of Umbilical Hernia in the Petus. Re- 
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Chancellor, C. W. Diaphragmatic Hernia. Amer. Journal Med. Sciences. 

Vol. XXX., N. S., p. 404. 1855. 
Chase, Heber. Treatise on the Radical Cure of Hernia by Instruments. 

Phil., 1836. 
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Instruments, etc. Phil., 1837. 
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Clark, J. C. Strangulated Crural Hernia. Western Lancet. Vol. XII., 

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Cloquet, J. Recherches Anatomiques sur les Heniies. 1817. 

Colles, A. Treatise on Surgical Anatomy. Part I. 

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Curling. T. B. Practical Treatise on Diseases of Testis. London, 1843. 
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D. 

Da Costa, J. M. Medical Diagnosis. 

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Darrah, William E. Drawings of the Anatomy of the Groin. Folio. Phil., 

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Herniarum Adnotationes. 1755. 



410 HEENIA. 

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417 



Wood, John. On Rupture. 1863. 

Application of Trusses to Hernia. London, 1878. 
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1850. 



A FEW OF THE OPERATORS ON HERNIA, 



Obsolete Topical Applications. 

Pabricius de Aquapendente. 

Lanfranc. 

Verduc. 

The Prior of Cabriere. 

Babynet. 

Mile. Devaux. 

A. Pare. 

Arnaud. 

Belmas. 

Compression, 
Celsus. 
Galen. 

Leonidas of Alexandria. 
Theodorus Aetius. 
De Salicet. 
Norsia. 
Blegny. 
Trecourt. 
Petit. 
Rareton. 
Juville. 
Pournier. 
Beaumont. 
Duplat. 

Position. 
Ravin. 
Riviere. 
De Hilden. 
Reneaume. 
Arnaud. 



Pedran. 

Hey. 

Rieck. 

Cauterization. 
Aetius. 

John, son of Serapion. 
Avicenna. 
Pranco. 
Albucasis. 
Roger. 
Brunnes. 
Guy de Chauliac. 
Petrus de Bonanti. 
Jean de Crepatis. 
Andre de Montpellier. 
Pierre d'Orliat. 
Little John. 
Maget. 
Gauthier. 
Monro. 



Incision. 



Arnaud. 
Lieutaud. 
Le Blanc. 
Bertrand. 



Excision. 



Paulus. 

Celsus. 

Bertrandi. 

Lanfranc. 

Arnaud. 



418 



HERNIA. 



Schmucker. 
Langenbeck. 

Ligature. 
Celsus. 
Saviard. 
Desault. 
Dupuytren. 
Guy de Chauliac. 
Martin. 
Nott 
John Wood of King's College 

Hospital, London. 
Sir W. Pergusson. 
Erichsen. 
T. Bryant. 
W. D. Spanton. 

Carbolized Catgut Ligature. 

Chas. Steele. 
Joseph Lister. 
H. O. Marcy. 
Annandale. 
Czerny. 

Suture. 
Celsus. 

Thomas Wood of Cincinnati. 
G. Dowell. 
Octavius White. 
S. R. Beckwith. 

Castration. 

This operation was mostly in the 
hands of quaeks. 

Gilded Point. 
Buchwall. 
Berault. 
A. Pare. 

Royal Suture. 
Pabricius de Aquapendente. 

Scarification. 

Le Blanc. 
Guerin. 



Organic Plugs. 

Sir A. Cooper 

Velpeau. 

Goyrand. 

A. H. Stephens. 

Moinichen. 

Scultetus. 

Garengeot. 

Graefe. 

Jameson. 

Redfern Davies. 

Gerdy. 

Signoroni. 

Leroy. 

D. Hayes Agnew. 

Belmas. 

Dupuytren. 

Acupuncture, 
Bonnet. 
Mayor. 
Wurtzer. 
Mosmer. 
Rothmund. 
Sigmund. 
Spencer Wells. 
Armsby. 
Riggs. 

Hachenburg. 
Malgaigne. 

Injection. 

Joseph Pancoast. 

Desault. 

Yelpean. 

W. H. Roberts. 

Woogencraft. 

Bowman. 

Geo. Heaton. 

Schwalbe. 

J. Mason Warren. 

Jos. H. Warren. 

Wm. Janney. 

H. S. Greeno. 

W. H. Heath. 

And many others. 



INDEX. 



INDEX. 



Abdomen, remarkable cure of wounded, 

137. 
Abdominal supporter, 319. 
Accidental Herniae, 37. 
Acquired Congenital Hernia, 16. 

" Hernial sac, 16. 
Action of Quercus alba, 381. 
Acupuncture as a cure, 107. 
Adhesions, 75. 
Adjustment of truss, 320. 
Adult, Hernia in, 22. 
Adventitious umbilical hernia, 20. 
After treatment of hernia, 172. 
Age as affecting Hernia, 44. 

" most suitable for injection, 177, 181. 
Agnew's instrument, 105. 

" method of cure, 105. 
Allis' herniotome, 220. 
Amussat's operation in artificial anus, 

304. 
Anatomical measurements, sliding and 

revolving rule for taking, 60. 
Anatomy of Hernia, 4, 48. 

" ' " " Femoral, 66, 160. 
" " " Inguinal, 51, 160. 
" " Strangulated, 48 et 

scq., 86. 
" " Umbilical, 48. 
Ancient prescription, 362. 
Animal ligatures in surgery, 119. 
Antiseptic carbolized catgut ligature, 
operations by the use of, 114, 270, 
274. 
Antiseptic ligature of neck of sac, 270. 
" treatment of hernia, 114, 270, 
274. 
Anus artificial, 232, 303. 
Arch, Femoral, 33, 69. 
Arteries, — 

Danger of wounding, 146, 

148, 221, 377. 
Deep Epigastric, 57. 
Femoral, 69. 



Arteries, — 

Superficial Epigastric, 66. 
" Circumflex Iliac, 
66. 
Superficial External Pudic, 
66. 
Artificial anus, 232, 303. 
Aspirating needle for Strangulated Her- 
nia, 216, 377. 
Author's Anatomical Truss, 321. 

Formula? for injection, 371. 
" Herniotomy Case, 221, 239, 377. 
" Instruments for Hernia, 142, 

144, 157. 
" Modification of Injection, 141, 
154. 
" " Kelotomy, 238. 

" New Instrument, 157, 373. 
" operation for Hernia, 134, 154, 

163, 165, 167, 168, 170. 
" operation for Hernia Femoral, 

168. 
" operation for Hernia Inguinal, 

165. 
" operation for Hernia Umbilical, 

170. 
" operation for Varicocele, 339. 
" Treatment after operations, 
172. 



B. 



Ball and Socket truss, 318. 
Bandages, 167, 169, 374. 
Belmas' method of cure, 105. 
Bernard on operations for Strangulated 

Hernia, 225. 
Bibliograplw, 403. 

Birkett on Strangulated Hernia, 208. 
Bonnet's method of cure, 106, 365. 
Breschet's operation for varicocele, 337. 
Bryant's Surgery, Diagrams from, 82, 

84. 
Bubo, 42. 



422 



INDEX. 



Bubonocele, 41. 

Buggy Spring truss, 112. 

Burn's ligament, 68. 

c. 

Calli sen's operation in artificial anus, 

303. 
Camper's Fascia, 5. 
Canal, Crural or Femoral, 69, 72. 
" Inguinal, 5, 56, QQ. 
" of Nuck, 8. 
Carbolized catgut as ligatures, 118. 
Cases. On observing, 174. 

" Record of interesting, 186, 386. 
Castration for hernia, 102, 364. 
Catgut as a ligature for hernia, 114, 

270, 274. 
Causes of failure by injection, 1 83, 379. 
" Hernia, 4, 17, 22, 25, 26, 28, 
31, 34, 266. 
" " Hydrocele, 327. 
" " success by injection, 134, 141, 
163, 177, 202, 379. 
" Varicocele, 335. 
Cauterization for Hernia, 98, 360, 363. 
Cerebral Hernia, 37. 
Chadwick, James R., on umbilical her- 
nia in foetus, 21. 
Circumcision for Hernia, 18. 
Clinical Reports. 

Author's, 394. 
Greeno's, 386. 
Heath's, 392. 
Cloquet on Hernia, 71. 
Codman, Benj. S., on trusses, 315. 
Colon, Hernia of transverse, 38 note. 
Common Hydrocele, 324. 
Compression for Hernia, 98. 
Concluding observations, 381. 
Conclusions of Czerny's " radical cure," 

300. 
Congenital Hernia, 4, 8, 14, 20, 37, 181. 
Hydrocele, 327. 
" Inguinal Hernia, 4, 8, 12. 
" Umbilical Hernia in foetus, 

20. 
Conjoined tendon, 54. 
Constitutional effects of hernia, 36. 
Cooper, Sir Astley, his hernia knife, 
220 ; opinions on hernia, 16, 55, 59, 
71, 74, 85, 346. 
Cord, Hydrocele of, 327. 
Cornil and Ranvier on fibro-plastic 

lymph, 368. 
Coverings, — 

Femoral Hernia, 74, 350. 
Inguinal " 74, 350. 
Cremaster muscle, 61. 
Cribriform fascia, 67. 



Crural. See Femoral. 

Curative treatment of hydrocele, 329. 

Cures of Hernia. — 

Acupuncture, 107. 

Annandale's, 270. 

Antiseptic, 114, 270, 274. 

Author's, 134, 141, 154. 

Castration, 102, 364. 

Cauterization, 98, 360, 363. 

Circumcision, 18. 

Compression, 98. 

Czerny's, 274. 

Dilation by organic plugs, 103. 

Dowell's, 109. 

Excision, 99, 359. 

Gilded point, 103, 244. 

Graefe's, 364. 

Incision, 99, 364. 

Injection, 128, 134, 206, 372. 

Ligature, 100, 114, 270, 274, 359. 

Position, 98. 

Royal Suture, 102. 

Scarification, 102. 

Spanton's, 243. 

Suture, 100, 359. 

Wood's, John, 108, 245. 
11 Thomas, 100. 

Wurtzer's, 104, 365. 
Cures of Hydrocele. — 

Excision, 331. 

Incision, 330. 

Injection, 331. 

Seton, 330. 

Theories of, 333-335. 
Cures, percentage of, 182, 384, 391. 
Curling on descent of testis, 9. 
Cystocele, 42, 344. 
Czerny's " radical cure," 274. 

" * " Conclusions of, 300. 

" " Summary of, 297. 



D. 



Danger of wounding epigastric artery, 

146, 148, 221, 377. 
Davenport's instrument, 143. 
Davies' Redfern instrument, 104. 
Deep crural arch, 69. 

" epigastric artery, 6Q. 

" Fascia, 67. 
Definition of safe operation, xvii. 
Demonstrators' knife, 340. 
Descent of testicle, 8-12. 
Development of hernia, 31-33. 
Diagnosis between Femoral and Inguinal 

hernia, 341. 
Diagnostic Tables, 78-81. 
Diagrams illustrating the different kinds 

of hernia, 82. 
Diaphragmatic or Phrenic hernia, 37. 



INDEX. 



423 



Diffused Hydrocele, 328. 
Direct Inguinal hernia, 41. 
Directors for strangulated hernia, 220. 
Displaced hernia, 90-92. 
Dowell's Buggy Spring truss, 112. 

" method of cure, 101, 109. 

" needles, 101. 
Dupuytren's operation in artificial anus, 
307. 



E. 



Effects of hernia, 35. 

' ' muscular exertion on causation 
of hernia, 30. 
Elongation of mesentery as cause of her- 
nia, 23. 
Empty hernial sacs Avith symptoms of 

strangulation, 348. 
Encysted or Infantile hernia, 16, 37. 

Hydrocele, 327. 
Enterocele, 42. 
Entero-epiplocele, 42. 
Enterotomy, 308. 
Eperon, .306. 
Epigastric Artery, — 

Danger of wounding, 146, 148, 221, 
377. 

Deep, 57. 

Superficial, 66. 
Epiplocele, 42. 
Excision as a cure, 99, 359. 
Exciting causes of hernia, 27, 34. 
Exertion as a cause of hernia, 27-31. 
Exomphalos, 38. 
External Abdominal ring, 56. 

" Inguinal hernia, 40. 

" oblique muscle, 52. 

" spermatic fascia, 53. 



F. 



Fabmcius ab Aquapendente on hernia, 

362. 
Failure, causes of, of injection for hernia, 

183, 379. 
Falciform process, 68. 
Fallopius ligament, 52. 
Fascia, — • 

Camper's, 5. 
Cribriform, 67. 
Deep or Fascia Lata, 67 
Intercolumnar or External Sperma- 
tic, 53. 
Internal oblique, 54. 
Propria, 71. 
Superficial, 6Q. 
Transversalis, 11, 55, 61. 
Femoral and Inguinal hernia, Diagnosis 
between, 311. 



Femoral Arch, 33, 69. 
" Canal, 69, 72. 

Hernia, 33, 42, 168, 212, 341. 
" " Anatomy of, 48, 66. 

" " Kelotomy in, 233. 

" " Rare form of, 212. 

" " Symptoms of, 51, 75. 

" ligament, 68. 
" ring, 34. 

" rupture, Gay's figures for, 234. 
Fibro-plastic lymph, 140, "368. 
First operator by Injection, 129, 302. 
Foetus, hernia in the, 21, 49. 
Formation of hernial sac, 72. 
Formulas, — 

Author's, 371. 
Heaton's, 371. 
French truss, double and single, 317. 
Frequency of hernia according to 
Age, 44. 
Kind, 43. 
Nationality, 47. 
Occupation, 45. 
' Population, 44, 845. 
Sex, 44. 

Side of body, 18, 47. 
Funicular process, 13. 

'i " Hernia into, 15. 



G. 



Gagneb£'s operation for varicocele, 338. 

Gangrene in strangulated hernia, 86. 

Gastrocele, 42, 344. 

Gay's operation for femoral rupture, 234. 

General remarks, 175. 

Gerdy's method of cure for hernia, 104. 

Gilded point as a cure for hernia, 103, 

244. 
Gimbernat's ligament, 52. 
Golding Bird's torsion forceps, 377. 
Graefe's operation for hernia, 364. 
Gubernaculum testis, 9. 
Guthrie on descent of testis, 10. 
Guy's Hospital, Author's operation at, 

167. 



H. 



Heaton's instruments, 142, 368. 
Hepatocele, 42, 344. 
Hernia, — 

Best age for injecting, 177, 181. 

Causation of, 4, 17, 22, 31. 

Cures of. See Cures. 

Development of, 31. 

Directors, 220. , 

Effects of, 33. 

Fabricius ab Aquapendente on, 362. 



424 



INDEX. 



Hernia, — 

Frequency of different kinds, 43 ; 

according to age, 44 ; occupation, 

45 ; population, 44, 345 ; race, 

47 ; sex, 44 ; side of body, 18, 47. 

In adults, 22. 

Kinds of, best treated, 177. 
Knife, — 

Allis's, 220. 

Author's, 221, 239, 377. 

Cooper's, 220. 

Hinge's, 220. 

Levi's, 220. 

Peter's, 220. 

Stewart's, 220. 
Of transverse colon, 38. 
Operations for, 18, 93, 359. 
Operators on, 417. 
Percentage of cures by injection, 

182, 384, 391. 
Reduction en bloc or en masse, 90. 

" by taxis, 209. 
Urinary bladder in, 21. 
Hernia, various kinds of, — 
Accidental, 37. 
Acquired Congenital, 16. 
Adventitious Umbilical, 20. 
Bubonocele, 41. 
Cerebral, 37. 

Congenita], 4, 8, 12, 14, 18, 37, 181. 
Crural, 42, 232. 
Diaphragmatic, 38. 
Displaced, 90. 

Encysted or Infantile, 16, 37. 
Enterocele, 42. 
Entero-epiplocele, 42. 
Epiplocele, 42. 
Exomphalos, 38. 
Femoral, 33, 42, Q6, 162, 168. 
Incarcerated, 43, 345. 
Indirect, 13. 

Infantile or Encysted, 16, 37. 
Inguinal, — 

External, 13, 40, 77, 165. 

Internal, 41, 165. 
Intermuscular, interparietal, or in- 
terstitial, 91, 352, 354. 
into Funicular process, 15. 
" Vaginal " 14. 

Irreducible, 43, 345. 
Ischiatic, 40. 
Lumbar, 40. 
Merocele, 42. 
Oblique, 40. 
Of infancy, 14. 
" linea alba, 22. 
" tunica vaginalis, 8, 13. 
" transverse colon, 38. 
Omphalocele, 38. 
Oscheocele, 42. 
Perineal, 40. 



Hernia, various kinds of, — 
Pudendal, 42. 
Reducible, 43, 75. 
Scrotal, 42. 

Strangulated, 43, 85, 208, 345, 381. 
Thyroid, 40. 
True Umbilical, 22. 
Umbilical, 19, 38, 48, 170, 233. 
Vaginal, 40. 
Ventral, 42. 
Ventro-inguinal, 42. 
Hernial sac, — 
Acquired, 16. 
Congenital Umbilical, 20. 
Consequence of fluid in, 76. 
Coverings of, 74, 350. 
Empty with svmptoms of strangula- 
tion, 348. 
Formation and nature of, 72. 
Inflammation of, 75, 87, 88, 348, 

351. 
in strangulated hernia, 86, 226, 227. 
Herniotomes, kinds of, 220. 
Herniotomy. See Kclototny. 
Hesselbach's triangle, 57. 
Hey's ligament, 68. 
Hinge's hernia director, 220. 
History of operations, 186, 359. 
Hodgen, Prof. John T., on Sayre's treat- 
ment as a cause of hernia, 28. See 
also 266. 
Hospital, Guy's, Author's operation at, 

167. 
Huette on strangulated hernia, 225. 
Hydrocele, — 

Causation of, 324. 
Common, 324. 
Curative treatment of, 329. 
Cures, — 

Excision, 331. 
Incision, 330. 
Injection, 331. 
Seton, 330. 
Theories of, 333. 
Diagnosis of, 326. 
Diffused, 328. 
Encysted, 327. 
Of Cord, 327. 
" Tunica vaginalis, 324. 
Operations for, 328. 
Palliative treatment of, 328. 
Hypodermic syringes, objections to, 145. 



I. 



Ilioinguinal nerve, 52. 
Incarcerated hernia, 43, 315. 
Incision as a cure, 99, 364. 
Increased visceral pressure as a cause of 
hernia, 26. 



INDEX. 



425 



Inefficiency of parietes as a cause of 

hernia, 25. 
Infantile or Encysted hernia, 16, 37. 
Inflammation of hernial sac, 75, 87, 88, 
348, 351. 
" Maisonneuve's treatment 

of, 368. 
treatment of, 136, 139, 311, 
368. 
Inguinal canal, 5, 56, 66. 
" hernia, 40. 
" " Anatomy of, 51. 

Inguinal hernia, External, 13, 40," 77, 
16*5. 
" " Indirect, 13. 

" Internal, 41, 165. 
" " Symptoms of, 51. 

" and Femoral hernia, diagnosis 
between, 341. 
Injection as a cure for hernia, 7, 134. 
" as modified by author, 141, 163. 
" causes of failure by, 183. 
" " " success by, 7, 134. 

" first operator by, 129, 302. 
operation by, 149, 206, 372. 
Instruments. — 
Agnew's, 105. 
Allis's herniotome, 220. 
Author's, 144, 157, 216, 239, 373. 
Cooper's hernia knife, 220. 
Davenport's, 143. 
Davies' Redfern, 104. 
Dowell's, 101. 
Heaton's, 142, 370. 
Hernia director, 220. 
Hinge's " 220. 
Janney's, 132. 
Levi's director, 220. 
Peter's " 220. 
Stewart's hernia knife, 220. 
Wurtzer's, 106. 
Intemperance as a cause of hernia, 29. 
Intercolumnar Fascia, 53. 
Intermuscular, interparietal, or intersti- 
tial hernia, 91, 352, 354. 
Internal abdominal ring, 6, 55. 

" oblique fascia, 54. 
Intestines, wounds of, 310. 
Introduction, xiii. 
Irreducible hernia, 43, 345. 
Ischiatic hernia, 40. 



J. 

Jameson's cure, 103. 
Janney on Injection, 130. 
" Instrument, 132. 



K. 

Kelotomy, 217-242. 

Author's modification of, 238. 
" new knife for, 239. 

Bernard's and Huette's method of, 
225 et seq. 

Gay's method of, 234. 

in Crural, 232. 

" Femoral, 222. 

" Inguinal, 217. 

" Umbilical, 233. 

Incision of sac in, 226, 227. 

Instruments for, 220 et seq. 

Key's method of, 223. 

Malgaigne's method for, 230. 

Multiple division in, 230. 

New knife for, 239, 377. 

Petit's method of, 222. 

Reduction in, 231, 376. 

Without opening sac, 221. 
Kinds of hernia, 37, 43. 

" as affecting occurrence, 43. 
" best treated, 177. 
Kingdon's Tables of Hernia, 46. 
Knife, new herniotomy, 239, 377. 



Life, time of, at which hernia occurs, 37. 
Ligaments, — 

Burn's, Hey's, or Femoral, 68. 

Gimbernat's, 52. 

Poupart's, 52. 

Triangular, 53. 
Ligation as a cure in varicocele. 

Intermediate, 338. 

Subcutaneous, 338. 
Ligature, — 

animal, in surgery, 119. 

as a cure for hernia, 98, 114, 270, 
274, 359. 

Dowell's subcutaneous, 112. 

of neck of hernial sac, 270. 

surgical operations without, 240. 
Linea alba, hernia of, 22. 
Lister's carbolized catgut, 120. 
Littre's operations in artificial anus, 303. 
Lumbar hernia, 40. 

M. 

Maisonneuve's treatment of inflamma- 
tion, 368. 

Malgaigne's diagnosis between Femoral 
and Inguinal hernia, 342. 

Malgaigne's operation for varicocele, 338. 

Marcy, H. O., Antiseptic treatment of 
hernia, 114. 

Measurements of the abdomen by Sit 
Astley Cooper, 59. 



426 



INDEX. 



Merocele, 42. 
Mesorchium, 9. 
Muscles, — 

Cremaster, 61. 

External oblique, 52. 

N. 

Navel, ruptured, 38. 
Nationality as affecting hernia, 47. 
Neck of sac, antiseptic ligature of, 114, 

270, 274. 
Needle, — 

aspirating, 216, 377. 

Dowell's, 101. 
Nerves, — 

Anterior Crural, 56. 

Genito " 52, 56. 

Ilio-Inguinal, 52, 67. 

0. 

Oak bark, action of, in hernia, 381. 
Oblique inguinal hernia, 13, 40. 
Obliteration of vaginal process, 13. 
Observing cases, 174. 
Occupation as affecting hernia, 45. 
Occupations most favorable for opera- 
tions for hernia, 177. 
Omentum, treatment of, 165, 232. 
Omphalocele, 38. 
Operations for artificial anus, 303. 

" Hernia, 91, 165,168,170, 
189,359,364. See also 

" Hydrocele, 328. 
" " Varicocele, 336. 

" " Wounds of Intestines, 

310. 
Operators on hernia, 417. 
Organic plugs as a cure for hernia, 103, 

245. 
Oscheocele, 42. 
Ossified tunica vaginalis, 346. 

P. 

Paget, Sir James, on strangulated her- 
nia, 87, 127. 
Palliative treatment of hydrocele, 328. 
Pancoast's operation for varicocele, 339. 
Pathology, — 

After injection, 140, 150, 379. 
Cornil and Ranvier on fibro-plastic 

lymph, 368. 
Gangrene in sac coverings, 87. 

" " strangulated hernia, 86. 

Patients, on the selection of, for treat- 
ment for hernia, 175. 
Percentage of cures by injection for her- 
nia, 182, 384, 391. 



Perineal hernia, 40. 
Peritoneum, — 

Davenport on, 134. 

Funicular process of, 13. 

in hernia, 346. 

John Wood on, 135. 

Nature of the, 74. 

Toleration of, illustrated, 136. 

Vaginal process of, 13. 
Peritonitis, efficacy of cold water or ice in 

cases of, 136, 139, 368. 
Persons in whom injections best succeed, 

176, 177, 181. 
Peter's hernia director, 220. 
Petit's operation of kelotomy,222. 
Phimosis a cause of hernia, 17. 
Phrenic or Diaphragmatic hernia, 38. 
Pillars of external ring, 4, 53. 
Plaster jacket a cause of hernia, 28, 266. 
Plugs, organic, as a cure for hernia, 103. 
Population as affecting hernia, 44. 
Position, — 

as a cure, 98. 

in author's operation, 163. 

" taxis, 209. 

of truss,- 314, 320. 
Poultices injurious in abdominal inflam- 
mations, 139. 
Poupart's ligament, 52. 
Predisposing causes of hernia, 26, 33. 
Prescription, quack, 362. 
Process, — 

Burns', 68. 

Falciform, 68. 
Processus vaginalis, 9. 
Proper position of truss in Inguinal 

hernia, 314, 320. 
Proper position of truss in Umbilical 

hernia, 314. 
Pudendal hernia, 42. 

Q. 

Quack prescription, 362. 

Quackery in treatment of hernia, 102, 

125, 364. 
Quercus alba. Action of in hernia, 381. 



R. 

Race of men, frequency of hernia ac- 
cording to, 47. 

Rachet truss, 317. 

Radical cure, 7, 93, 97, 125, 128, 155. 

Raynaud's operation for varicocele, 338. 

Record of interesting cases, 186, 386. 

Reducible hernia, 43. 

" " symptoms of, 75. 

Reduction in strangulated hernia, 209, 
231, 376. 



INDEX. 



427 



Reduction of hernia, en bloc or en masse, 

90, 352. 
Reports, Clinical, 386. 
Resume, 379. 

Ricord's operation for varicocele, 339. 
Rigaud's " " " 337. 

Rings, — 

External inguinal, 53, 56. 

Femoral or crural, 34, 70. 

Internal inguinal, 5, 55. 
Royal suture as a cure for hernia, 102. 
Ruptured navel, 38. 

s. 

Sac, — 

acquired hernial, 16. 
congenital umbilical, 20. 
consequence of fluid in, 76. 
coverings of hernial, 74, 350. 
formation and nature of, 72. 
inflammation of hernial, 75, 87, 

88, 348, 351. 
in strangulated hernia, 86, 226, 
227. 
Saphenous opening, 67. 
Sayre's treatment as a cause of hernia, 

28, 266. 
Scarification as a cure for hernia, 102. 
Scarpa, — 

cellular structure described by, 61. 
on texture of peritoneum, 74. 
opinions on various points, 15, 22, 

23. 
triangle, 61. 
Schmalkalden's operation in artificial 

anus, 307. 
Scrotal hernia, 42. 

Sedentary habits a cause of hernia, 30. 
Sex as affecting hernia, 44. 
Side of body as affecting hernia, 47. 
Smith, Willard E., viii., 396. 
Span ton, W. D., immediate cure of 

hernia, 243. 
Specialists, 94. 
Spermatic cord, 5, 61. 

" " relation of, to sac, 61, 66. 

Spica bandage, 169. 
Spiral spring truss, 316. 
Stewart's hernia knife, 220. 
Stranguated hernia, 43, 85, 208, 345, 
351. 
" " Birkett on, 208. 

" operations for, 91. 
11 " reduction of. 209. 

" " reduction of, bv J. 

C. Warren, 375. 
" " symptoms simu- 

lating, 348. 
" taxis in, 209. 
" " treatment of, 225. 

Strangulation, symptoms of, 88, 351. 



Subcutaneous ligature for cure of her- 
nia, 109. 
Success of injection for hernia depend- 
ing upon age of patient, 178. 
" kind of hernia, 177. 
" selection of patients, 175. 
" treatment, 172, 183, 379. 
Summary of Czerny's "radical cure," 

297. 
Superficial circumflex iliac, 66. 
epigastric, 66. 
external pudic, 66. 
Suppuration as cause of failure of injec- 
tion for hernia, 379. 
Surgery, animal ligatures in, 119. 
Surgical operations without ligatures 

illustrated, 240. 
Suture as a cure for hernia, 100, 359. 
Symptoms, — 

of reducible hernia, 75. 
of strangulated hernia, 85. 
of umbilical hernia, 48. 
simulating strangulation, 348. 
Syringe for injecting hernia, 157, 373. 
" objection to hypodermic, 145. 



T. 



Tables of Diagnosis, 78-81. 

Taxis and position for, 209. 

Tendon, conjoined, 54. 

Testicle, 8, 15. 

Theories of cure of hydrocele, 333-335. 

Theory of cause of varicocele, 335. 

Thyroid hernia, 40. 

Toleration of peritoneum, illustrated, 

136. 
Trades in which hernia is most fre- 
quent, 46. 
Transversalis fascia, 11, 55, 61. 
Transverse colon, Hernia of, 38. 
Treatment after operation for hernia, 
172. 

" of inflammation, 136, 139, 
311, 367. 

" " omentum, 165, 232. 

" " strangulated hernia as 
given by Bernard and 
Huette, 225. 
Triangles, — 

Hesselbach's, 57. 

Scarpa's, 61. 
Triangular ligament, 53. 
True umbilical hernia, 22. 
Trusses, — 

Abdominal supporter, 319. 

Adjustment of, 320. 

Anatomical, 821. 

Hall and Socket, 318. 

Codman, l>enj. S., concerning, 315. 

Do well's Buggy Spring, 112. 



428 



INDEX. 



French, double and single, 317. 
Proper position in inguinal hernia, 
314, 320. 
" " in umbilical hernia, 

314. 
Eachet, 317. 
Spiral spring pad, 316. 
Umbilical, 318. 
Tunica vaginalis, 8. 

Hernia of, 8, 13. 
Hydrocele of, 324. 
11 " ossified, 346. 



U. 

Umbilical, Adventitious hernia, 20. 
" Anatomy of, hernia, 48. 

" belt, child's and adult's, 319. 

" Hernia, 19, 38, 48, 170. 

" " in adult, 50. 

" "in child, 50. 

" " in fetus, 19, 49. 

symptoms of, 51. 
" true, 22. 
11 truss, 318. 
Umbilicus, Pain at, in strangulated 

hernia, 351. 
Uterus, remarkable rupture of, 138. 



V. 

Vaginal Hernia, 40. 
" Hernia into, 14. 
" process, 13. 



Varicocele, — 

Causes of, 335. 
Operations for, 336. 

Author's, 339. 

Breschet's, 337. 

Gagnebe's, 338. 

T . , . j Immediate, 338. 

legation | subcubtaneous, 336. 

Malgaigne's, 338. 

Pancoast's, 339. 

Eicord's, 339. 

Eigaud's, 337. 

Velpeau's, 337. 

Vidal de Cassis', 339. 
Theory of, 335. 
Velpeau's operation for varicocele, 337. 
Ventral hernia, 42, 80. 
Ventro-inguinal hernia, 42. 
Vidal de Cassis' operation for varicocele, 
339. 

w. 

Warren, C. Everett, Demonstrator's 
knife, 340. 
" J. Collins, operation for stran- 
gulated hernia, 375. 
White's ligature for hernia, 101. 
Wood, John, — 

method of cure, 108, 245. 
on the peritoneum, 135. 
Wood, Thomas, — 

method of cure, 100. 
Wounds of the intestines, 310. 
Wurtzer's cure for hernia, 106. 



University Press : John Wilson & Son, Cambridge. 



RECOMMENDATIONS AND REVIEWS 

OF THE 

AUTHOR'S LABOES AND STUDIES IN DEVELOPING 
THE SUBJECT OF HERNIA. 



NOTICES OF FIRST EDITION. 



53 Upper Brook Street, 
Grosvenor Square, Feb. 7, 1S81. 

Dear Dr. Warren, — I have to thank you for your book, which 
1 have carefully gone over, and I can see that you have bestowed 
much time and work in its preparation. I only hope you may have 
pointed out a way for us to work in and radically cure hernia. I am 
now looking up the case of mine you operated upon at Guy's, and as 
soon as I can find time I will report the case in full in the London 
Lancet. 

Your herniotome and rotary wedge needles and catheters I like 
much. 

"With kind regards, believe me, sincerely yours, 

Thomas Bryant, F.R.C.S. 



58 Beacon Street, Boston. 

My dear Dr. "Warren, — I have to thank you for your kindness 

in presenting me a copy of your very interesting work on Hernia, 

which I have already glanced over, and anticipate reading with much 

interest. 

I am, yours very truly, 

John C. Warren, M.D. 



I would sincerely thank you for the service you have done to the 

profession in openly, clearly, and fully making known and describing 

an innovation in surgery of considerable value, but which had by 

others been so long and so shamefully kept a mystery and a "secret." 

Yours very truly, 

Henry A. Martin, M.D. 
27 Dudley Street, Boston, Mass., 

Jan. 21, 1381. 



4 NOTICES OF FIEST EDITION. 

35 Wimpole Street, W., Jan. 31, 1881. 

Dear Dr. Warren, — On my return from Rome, I find your com- 
prehensive monograph on Hernia. I must at once, without delay, send 
you my best acknowledgments for the kind and too flattering position 
you have accorded to me in connection therewith. Be assured I highly 
appreciate it. 

I see the work is fully illustrated, and enters on your experience 
and views relative to your system of applying injection. This I hope 
to devote some early leisure to investigate. I shall be interested in 
seeing and in trying your new instrument (the Thompson American 
catheter). I am always surrounded by strangers and visitors, and 
shall be happy to give it a trial. 

Meantime, with best wishes, believe me, yours very truly, 

Henry Thompson, F.R.C.S. 



In addition to these, letters of commendation have been received 
from Prof. S. D. Gross, M.D., LL.D., D.C.L., from Prof. C. E. 
Brown-Sequard, M.D., LL.D., and from many others. 



PRESS NOTICES OF FIRST EDITION. 



From London Lancet. 



Dr. Warren has devoted much attention to the subject of hernia. 
His operation for the radical cure will prove of interest to most English 
surgeons. 

Prom Philadelphia Medical and Surgical Reporter. 

Dr. Warren has made many improvements in the forms of the in- 
struments used, in the details of the procedure, and in the after treat- 
ment. These are fully described in the volume before us, and it is 
recommended to all who wish to study up this apparently highly 
satisfactory method for the radical cure of a large class of hernias. 

From Virginia Medical Monthly. 

The author of this book has gained for himself an enviable profes- 
sional distinction, in that he is an accurate observer, a careful student, 
and an original contributor of many valuable suggestions to prac- 
titioners, and the devisor of useful instruments and appliances. But 
his most worthy contributions to the art of medicine relate to the sub- 
ject indicated by the title of the treatise before us. This work, in 
addition to giving a short sketch of the various operations by other 
authors for the cure of hernia that are most worthy of mention, — 
such as those of Wood, Dowell, &c, — advocates especially a treatment 
by subcutaneous injections of infusion of white-oak bark, — modifica- 
tions of the late Prof. Joseph Pancoast's operation. These injections 
are thrown into the tissues composing the hernial rings, after thorough 
reduction, of course, of the hernia, and by their sufficiently stimulant 
effect sets up adhesive inflammation, which closes the opening. Full 
credits are given to Heaton and others for their several suggestions. 
Our want of space will not allow us to go more into detail. The 



6 PRESS NOTICES OF FIRST EDITION. 

operations by various authors for strangulated hernia are thoroughly 
reviewed, and the author's valuable modification of the operation of 
kelotomy is tersely but clearly stated. Dr. Warren also takes advan- 
tage of this publication to present many new instruments of his own 
devising. We can only add that this work, while the most recent, is 
also practically the most valuable contribution to the subject of hernia 
that we now have. Every surgeon should have the book. 

From Physician and Surgeon, Ann Arbor, Mich. 

He has improved the injection method, especially by the invention 
of suitable syringes. He has presented his improved method to the 
British Medical Association and to the Academy of Medicine at Paris, 
where it has been received with favor. The volume contains a de- 
scription of the various methods of operating for hernia and the 
instruments used. The subjects are discussed thoroughly, and the 
methods of operation described with sufficient detail. 

From Pacific Medical and Surgical Journal. 

This is the most complete monograph on Hernia that we know of. 
Great pains has been taken by the author in the collection of authentic 
materials, his object being not alone to present his own methods, but 
also those of other surgeons of eminence in all countries. The book 
is printed with great neatness, and the illustrations are excellent. 

From Maryland Medical Journal. 

This work has been written with a view of giving a short sketch of 
the various operations for the cure of hernia. Much labor seems to 
have been spent in consulting authorities and presenting trustworthy 
references. 

The author offers much that is practical, the result of some years of 
study and experience. Chapter V. is entirely taken up in explaining 
the author's operation for the cure of hernia by subcutaneous injec- 
tions which he has developed after much labor and effort, all the 
methods of which are entirely original. He also offers improved 
methods for kelotomy. The book is fully illustrated. 



PRESS NOTICES OF FIRST EDITION. 7 

From New York Medical Gazette. 

The author's object in placing this monograph before the profession 
he states to be " to give a short sketch of the various operations for 
the cure of hernia that are most worthy of mention, in order that the 
busy practitioner could refer to them without wading through whole 
volumes." This is a very laudable purpose, and Dr. Warren has 
carried out his design. 

He has impartially described the various operations that have from 
time to time, and -at the present, day, had their adherents from the 
ranks of eminent medical men. He has naturally given preponderat- 
ing space to the description of the operation he especially advocates. 

One advantage of this operation is expressed by Dr. Warren when 
he says, "if it should not be successful we have put the patient to 
but little pain, inconvenience, or danger ; and if we do not fully 
succeed, we have not left our patient worse than we found him, as 
there is always a partial if not a full occlusion of the rings." 

The English edition of the work has been received with general 
favor ; we believe it a thorough presentation of the more salient 
features of hernia and the different operations for cure selected from 
authentic sources, and, as such, its Americanized form will be welcome 
on this side of the water, and the prophet have honor in his own 
country. 

From St. Louis Medical and Surgical Journal. 

Dr. Warren, some time ago, contributed a paper on a new method 
of operating radically for hernia, and in his study of the various oper- 
ations he brought them together iu this volume, at the same time 
giving a general outline on hernia. 

To the author is due a great deal of work in this field and the spiral 
needle in these injections, together with a very ingenious syringe. 
The spiral principle has been further extended by him to aspirating 
needles, trocars, uterine sounds, catheters, the Bigelow evacuating 
tube, &c. 

We must not omit mentioning the extended notice which Dr. Warren 
bestows upon trusses and upon the anatomy of hernia, which he 
treats in a clear and concise manner. The book is deserving, and 
will no doubt be appreciated by that large class of practitioners who 



8 PRESS NOTICES OF FIRST EDITION. 

have but little time to bestow to their books, and who wish to realize 
immediately the benefits of whatever reading they may indulge in. 
It is a clear and short expose of hernia and its treatment. 

From Cincinnati Sanitary News. 

Dr. Warren is already well and favorably known to the medical 
world as a writer on hernia and other surgical topics. His present 
work is the result of years of experience and careful study, and, al- 
though the subcutaneous treatment of hernia has been known to a 
limited extent for years, he has brought it to such perfection that the 
matter of his excellent book is new to the mass of the profession. 

To the general practitioner, who has frequently to deal with hernias, 
and who neglects to treat them because of the well-known dangers of 
the knife, this book will be particularly welcome, as affording him a 
ready and safe method for the successful management of his cases. 

From St. Louis Courier. 

This is an excellent work on a subject that has not been as fully 
developed as the other parts of surgery. The plan pursued is simple, 
and so plainly described that the merest tyro in surgery can success- 
fully perform the operations. 

From Chicago Medical Review. 
It contains much matter of medico-historical interest. 

From Clinical Neivs, Philadelphia. 

The operation for the various forms of hernia by hypodermic injec- 
tion, as well as the after-treatment, is fully discussed and described by 
the author, who believes, and with good reason too, that it is attended 
with greater success than any other method known to the profession. 
Not only is this true, but it is wholly unaccompanied by even any 
serious risk to life, which cannot be said of the more heroic surgical 
procedure resorted to in this disease. 

This method of treatment has been pursued by the profession with 
variable fortune for nearly half a century, and the principle lying at 



PRESS NOTICES OF FIRST EDITION. 9 

its basis is the generation of an amount of inflammatory disturbance 
at the hernial seat sufficient to close the opening with plastic adhe- 
sions. This is the key to its successful practice, and it is not only 
evident that this prerequisite varies in every case, but also that a large 
amount of time, ingenuity, and experiment must have been expended 
in order to meet it favorably in any case, thus giving adequate reason 
for the unsatisfactory results that were obtained in the early history 
of the operation. 

Some space is also devoted to a discussion of kelotomy, and import- 
ant suggestions are made for the modification and improvement of this 
operation. A full bibliography of hernia completes the work. 

It is a valuable and interesting production, and we express the 
hope that it may find its way into the library of every practitioner in 
the land. 

From Peoria Medical Monthly. 

The method of subcutaneous injection has given a larger percentage 
of cures than any other. It is safe, for no fatal results have yet 
occurred from it ; and we think that, from the exact and lucid descrip- 
tion and explanation given by Dr. Warren, any man of good ana- 
tomical knowledge and surgical experience may make it successfully. 
At any rate, we hope this book may bring it fully and prominently 
before the profession, that it may be carefully tested, and its merits 
decided upon. 

We can confidently recommend this work to our readers as one of 
the most interesting and instructive ever brought to our notice. 

From Buffalo Medical and Surgical Journal. 

The author has improved the operation, and perfected and invented 
new instruments. The operation deserves more attention than has 
heretofore been granted it. 

From Michigan Medical News. 

While this book contains a general consideration of the whole sub- 
ject of hernia, its anatomy, and the various operations for its relief. - 
its distinctive feature is the consideration of the operation for radical 
cure of reducible hernia by subcutaneous injection. This operation is 



10 PRESS NOTICES OF FIRST EDITION. 

based on advanced ideas regarding the susceptibility of the peritoneum 
to wounds. The liability to peritonitis after wounds of the perito- 
neum is not so great as was formerly supposed. 

To those desiring a full consideration of this important procedure 
in the treatment of hernia we commend this book. Dr. Warren has. 
identified himself very closely with the operation, and has, by his 
successful performances of it, both in this country and in Europe, won 
for himself the right to speak authoritatively regarding it. 

From Philadelphia Medical Bulletin. 

This work sheds a remarkable degree of light upon the history of 
the various operations performed for the cure of hernia, the great bug- 
bear of surgeons of the past and present. In regard to the operation 
as now improved and performed by Dr. Jos. H. Warren for some years 
past, and in numerous cases with brilliant results, we think the very 
highest honor is due for his untiring energy in striving to perfect an 
operation which had fulfilled so much, and which, as now practised 
by him, must prove an unqualified boon to the profession, as it already . 
has to those who were suffering from hernia, and who have passed 
from his skilful hands cured. 

The work contains a valuable instructive table on the differential 
diagnosis of hernia. The author's description of the several forms of 
hernia, inguinal, oblique and direct, femoral, umbilical, ventral, &c, 
evinces the fine anatomist and skilled surgeon. 

The work is amply illustrated with fine wood-cnts and diagrams of 
clinical cases and instruments used, of which among the latter promi- 
nently stands forth the syringej devised and used by the author in 
making subcutaneous injections for the perfect cure of hernia. Also, 
valuable chapters on the performance of herniotomy and on the appli- 
cation of trusses. 

This effort on the part of the author to arouse fully the attention of 
surgeons throughout the land to this great achievement will, no doubt, 
command that thoughtful consideration and following which it so 
eminently merits. 

From Southern Medical Record, Atlanta, Ga. 

The difficult subject of hernia is here treated in an able and lucid 
manner, and the new suggestions and new instruments presented will 



PRESS NOTICES OF FIRST EDITION. n 

give to the work especial interest. The practitioner, and especially 
the surgeon, will find it a most useful and valuable addition to the 
medical library. 

From New England Medical Gazette. 

Dr. Warren has made many contributions to medical journals, has 
invented several new instruments for facilitating it, and has com- 
pounded a fluid for injection which he considers superior to Dr. 
Heaton's Quercus alba. His book is elaborate, introducing, besides 
this special operation, a great deal of general information on hernias. 

He has produced a very interesting as well as valuable book, which 
w r e hope will have a large sale, and spread the knowledge of this 
beautiful operation. 

From North Carolina Medical Journal. 

We have read this book with great interest. It should be carefullj r 
read, as it has peculiar merits, among others a marked degree of 
individuality. We trust this operation may have a fair triaL 

From Nashville Journal of Medicine and Surgery. 

This admirable work is an exposition of the treatment of hernia by 
subcutaneous injections and concise descriptions of all the operations 
for the radical cure of hernia. The plan is simple, devoid of danger, 
and generally successful. It is certainly worthy of trial, and we hope 
that in a few years it will be established as a generally accepted sur- 
gical procedure. 

The book is well written, well illustrated, and well published. 

I'rom Medical Journal, Edinburgh, Scotland. 

In this book Dr. Warren has favored the profession with an account 
of his method of treating hernia by injecting a stimulating fluid into 
the tissues which immediately surround the apertures, and so promot- 
ing closure by the effusion of plastic lymph. 

The operation consists of several stages, — first, the complete return 
of the hernia; next, the insertion of a fine hypodermic needle (which 
is blunt-pointed to prevent injury of important structures), from which 



32 PEESS NOTICES OF FIRST EDITION. 

a few drops of an irritating fluid is injected into the cellular tissue at 
the internal and external ring, and also along the canal (in oblique 
inguinal hernia). As a result of this operation inflammation is set up 
(as in the case of an injected hydrocele), which lasts for some days, 
during which time the patient is kept in bed, and cold applied over 
the inflamed and swollen part. To give the irritated textures oppor- 
tunity to become agglutinated, the patient must be kept in bed for a 
fortnight or three weeks. We recommend this operation to practical 
surgeons for a fair trial. 

We found our recommendation mainly on an anatomical fact which 
Dr. Warren points out, and which, though it is not new to any one, 
is apt to be forgotten by surgeons, from the manner in which they are 
accustomed to speak of the hernial openings as " rings." The fact is 
this, that these so-called rings are not rings at all, but have their walls 
in contact (generally), except when they are separated by the hernial 
protrusion. It seems natural enough, when we remember this fact, 
that if we can irritate these tissues in such a manner as to make their 
opposing surfaces become covered with plastic lymph, their subsequent 
fusion together is merely a question of rest and time. 



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